37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 289600 |
Time | |
Date | 199411 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : phl |
State Reference | PA |
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 | B737-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 210 flight time total : 18000 flight time type : 210 |
ASRS Report | 289600 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The captain called for the before start checklist. I started reading it and he responded with the appropriate answers. Normally what I have done in the past when reading this checklist is to keep my finger on it and read the 5 items pertaining to the overhead from memory, while I look up and verified that the switches were in the right position. Then I would look back down at the checklist to verify that everything was properly covered. Technically speaking, this was improper procedure, but I guess I did it this way for smoother flow and what I thought was efficiency of time. However, the company has recently stressed precise, proper usage of the checklists. So, in an effort to comply, I read the checklist this time through all 5 overhead items (without looking up to verify after each item), and then looked up at the end of these 5 items to make sure that the switches were indeed in the proper position as the captain had answered. The only problem was I missed the first item - - the fuel panel. For whatever reason, the captain had not turned on the center tank fuel pumps. Procedures stipulate that when you have fuel in the center tank, you burn that fuel first, then the fuel in the mains (wings). When we got to cruise altitude, that is when the captain discovered the problem. He turned on the center tank pumps at that time, but due to the duration of the trip, there was not enough time left in the trip to burn off all fuel in the center tank. We were going to have to therefore land with fuel in the center tank, and less than full wing tanks, as we used wing fuel for takeoff, climb and initial cruise. This is not the recommended confign to be in. Possibly one of the reasons this happened was that we had much more fuel than normal for this trip (normally fuel in the wing tanks is enough). But the company was having us tanker fuel I guess, due to fuel costs at destination. And because of this, perhaps the captain didn't associate center tank pumps with this trip during the before start checklist. And his final backup, me, was busy trying to reset my old nonstandard ways of doing things and I failed to catch his mistake. Moral: for the remaining 3 days of that trip, I read each item individually, then looked up to verify that the item was indeed in the proper position, before proceeding to the next item. Needless to say, this is the way I will do it from now on -- the way it's supposed to be done. Little anecdote: 3 yrs ago, a captain told me I was too slow reading the checklist, that I was slower than other first officer's. Being his same age (early 50's) and not one to be intimidated, we discussed it till I actually had him agree that was not a criteria for being a good first officer, but to accurately accomplish the checklist was. However, in retrospect, perhaps his words did 'sting' a little and I started trying to 'speed' things up a little to comply with the majority. Perhaps this is one reason why I developed the bad habit on the overhead items.
Original NASA ASRS Text
Title: FLC MISCONFIGURED FUEL PANEL DUE TO FLAWED PERFORMANCE OF THE CHKLIST.
Narrative: THE CAPT CALLED FOR THE BEFORE START CHKLIST. I STARTED READING IT AND HE RESPONDED WITH THE APPROPRIATE ANSWERS. NORMALLY WHAT I HAVE DONE IN THE PAST WHEN READING THIS CHKLIST IS TO KEEP MY FINGER ON IT AND READ THE 5 ITEMS PERTAINING TO THE OVERHEAD FROM MEMORY, WHILE I LOOK UP AND VERIFIED THAT THE SWITCHES WERE IN THE RIGHT POS. THEN I WOULD LOOK BACK DOWN AT THE CHKLIST TO VERIFY THAT EVERYTHING WAS PROPERLY COVERED. TECHNICALLY SPEAKING, THIS WAS IMPROPER PROC, BUT I GUESS I DID IT THIS WAY FOR SMOOTHER FLOW AND WHAT I THOUGHT WAS EFFICIENCY OF TIME. HOWEVER, THE COMPANY HAS RECENTLY STRESSED PRECISE, PROPER USAGE OF THE CHKLISTS. SO, IN AN EFFORT TO COMPLY, I READ THE CHKLIST THIS TIME THROUGH ALL 5 OVERHEAD ITEMS (WITHOUT LOOKING UP TO VERIFY AFTER EACH ITEM), AND THEN LOOKED UP AT THE END OF THESE 5 ITEMS TO MAKE SURE THAT THE SWITCHES WERE INDEED IN THE PROPER POS AS THE CAPT HAD ANSWERED. THE ONLY PROB WAS I MISSED THE FIRST ITEM - - THE FUEL PANEL. FOR WHATEVER REASON, THE CAPT HAD NOT TURNED ON THE CTR TANK FUEL PUMPS. PROCS STIPULATE THAT WHEN YOU HAVE FUEL IN THE CTR TANK, YOU BURN THAT FUEL FIRST, THEN THE FUEL IN THE MAINS (WINGS). WHEN WE GOT TO CRUISE ALT, THAT IS WHEN THE CAPT DISCOVERED THE PROB. HE TURNED ON THE CTR TANK PUMPS AT THAT TIME, BUT DUE TO THE DURATION OF THE TRIP, THERE WAS NOT ENOUGH TIME LEFT IN THE TRIP TO BURN OFF ALL FUEL IN THE CTR TANK. WE WERE GOING TO HAVE TO THEREFORE LAND WITH FUEL IN THE CTR TANK, AND LESS THAN FULL WING TANKS, AS WE USED WING FUEL FOR TKOF, CLB AND INITIAL CRUISE. THIS IS NOT THE RECOMMENDED CONFIGN TO BE IN. POSSIBLY ONE OF THE REASONS THIS HAPPENED WAS THAT WE HAD MUCH MORE FUEL THAN NORMAL FOR THIS TRIP (NORMALLY FUEL IN THE WING TANKS IS ENOUGH). BUT THE COMPANY WAS HAVING US TANKER FUEL I GUESS, DUE TO FUEL COSTS AT DEST. AND BECAUSE OF THIS, PERHAPS THE CAPT DIDN'T ASSOCIATE CTR TANK PUMPS WITH THIS TRIP DURING THE BEFORE START CHKLIST. AND HIS FINAL BACKUP, ME, WAS BUSY TRYING TO RESET MY OLD NONSTANDARD WAYS OF DOING THINGS AND I FAILED TO CATCH HIS MISTAKE. MORAL: FOR THE REMAINING 3 DAYS OF THAT TRIP, I READ EACH ITEM INDIVIDUALLY, THEN LOOKED UP TO VERIFY THAT THE ITEM WAS INDEED IN THE PROPER POS, BEFORE PROCEEDING TO THE NEXT ITEM. NEEDLESS TO SAY, THIS IS THE WAY I WILL DO IT FROM NOW ON -- THE WAY IT'S SUPPOSED TO BE DONE. LITTLE ANECDOTE: 3 YRS AGO, A CAPT TOLD ME I WAS TOO SLOW READING THE CHKLIST, THAT I WAS SLOWER THAN OTHER FO'S. BEING HIS SAME AGE (EARLY 50'S) AND NOT ONE TO BE INTIMIDATED, WE DISCUSSED IT TILL I ACTUALLY HAD HIM AGREE THAT WAS NOT A CRITERIA FOR BEING A GOOD FO, BUT TO ACCURATELY ACCOMPLISH THE CHKLIST WAS. HOWEVER, IN RETROSPECT, PERHAPS HIS WORDS DID 'STING' A LITTLE AND I STARTED TRYING TO 'SPD' THINGS UP A LITTLE TO COMPLY WITH THE MAJORITY. PERHAPS THIS IS ONE REASON WHY I DEVELOPED THE BAD HABIT ON THE OVERHEAD ITEMS.
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.