37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 297772 |
Time | |
Date | 199503 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : lbf |
State Reference | NE |
Altitude | msl bound lower : 7000 msl bound upper : 7000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zdv tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Commander 680 All Series |
Operating Under FAR Part | Part 135 |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 214 flight time total : 3364 flight time type : 270 |
ASRS Report | 297772 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Possibly not operating an airplane in compliance with the flight manual. On the night of feb/mon/95, I departed on a scheduled cargo run. It was my first time on this particular run. As part of my preparation I had talked with a pilot who normally flies the run, and the company director of training. I had previously flown into all of the airports except one, and I flew the type of aircraft I was taking regularly. I made normal preflight planing preparations, and felt comfortable about the flight. The route of flight normally has 3 stops. Normally we drop off and pick up cargo at all point and take on fuel at the first. On this evening the first stop was forecast to go as low as 100 ft overcast, with possible light to moderate ice in the clouds. There was no cargo for that stop and the latest hourly showed 300 ft overcast, light rain and a surface temperature near freezing. I was concerned about ice. I elected to add fuel after the aircraft was loaded and overfly this airport. I determined that after going to my destination, then the alternate, there would be 48 mins of fuel on board. The trip was uneventful and on schedule until the final destination. I shot the VOR approach twice and missed both times. Instead of going to the alternate, I chose to return to the previous stop. I had easily made it in on the ILS an hour earlier, the WX was essentially the same, and I would have a tailwind going back. The distance was only slightly longer, 108 mi to the previous stop verses 102 mi to the alternate. On the way back, I used the remaining fuel out of the auxiliary tanks to leave as much fuel as possible in the center tank for the approach and landing. The left engine fuel selector was on the auxiliary tank when the left engine hesitated. I turned the left boost pump on and switched the left fuel selector back to the center tank. The engine ran for about 2 mins and then quit. I went through the aircraft emergency procedures, and allowed some time for the left engine to restart on the center tank. It did not. I declared an emergency and landed. After the landing and taxiing to the ramp, I inspected the left engine. There was no obvious damage to the engine. I started the engine and did a thorough run up using the center tank for the fuel source. The aircraft was also inspected by mechanics. They put fuel in the auxiliary tanks and performed at least 2 very thorough run-ups using both engines and both the main and the auxiliary tanks as the fuel source. They could not duplicate the problem on the ground. It is possible that I ran the left auxiliary tank dry. The flight manual for the aircraft specifically cautions the pilot not to let this happen. The flight manual also states that the takeoff and landing should be done with the fuel selectors on the center tank. The hesitation may have been caused by water or some other type of fuel contamination in the left auxiliary tank. What I see from the occurrence is just how little 45 mins of fuel is. If I had my usual 1 1/2 hour - 2 hour fuel reserve on board, I would not have allowed the auxiliary tanks to get any where near empty. For this trip, in order to haul all of the cargo the customer wanted to send, I chose to go with minimum fuel. I have relearned how important it is to be conservative in IFR WX. In retrospect I could have done several things to make the flight safer: 1) ask the customer to not put as much freight on so I could carry more fuel. 2) ask the linemen to come out and fuel the aircraft after hours at my first stop. There would have been a small charge and possibly a delay. 3) wait for better WX at the destination.
Original NASA ASRS Text
Title: PLT FEELS HE MAY NOT HAVE OPERATED HIS ACFT IN ACCORDANCE WITH THE ACFT FLT MANUAL.
Narrative: POSSIBLY NOT OPERATING AN AIRPLANE IN COMPLIANCE WITH THE FLT MANUAL. ON THE NIGHT OF FEB/MON/95, I DEPARTED ON A SCHEDULED CARGO RUN. IT WAS MY FIRST TIME ON THIS PARTICULAR RUN. AS PART OF MY PREPARATION I HAD TALKED WITH A PLT WHO NORMALLY FLIES THE RUN, AND THE COMPANY DIRECTOR OF TRAINING. I HAD PREVIOUSLY FLOWN INTO ALL OF THE ARPTS EXCEPT ONE, AND I FLEW THE TYPE OF ACFT I WAS TAKING REGULARLY. I MADE NORMAL PREFLT PLANING PREPARATIONS, AND FELT COMFORTABLE ABOUT THE FLT. THE RTE OF FLT NORMALLY HAS 3 STOPS. NORMALLY WE DROP OFF AND PICK UP CARGO AT ALL POINT AND TAKE ON FUEL AT THE FIRST. ON THIS EVENING THE FIRST STOP WAS FORECAST TO GO AS LOW AS 100 FT OVCST, WITH POSSIBLE LIGHT TO MODERATE ICE IN THE CLOUDS. THERE WAS NO CARGO FOR THAT STOP AND THE LATEST HRLY SHOWED 300 FT OVCST, LIGHT RAIN AND A SURFACE TEMP NEAR FREEZING. I WAS CONCERNED ABOUT ICE. I ELECTED TO ADD FUEL AFTER THE ACFT WAS LOADED AND OVERFLY THIS ARPT. I DETERMINED THAT AFTER GOING TO MY DEST, THEN THE ALTERNATE, THERE WOULD BE 48 MINS OF FUEL ON BOARD. THE TRIP WAS UNEVENTFUL AND ON SCHEDULE UNTIL THE FINAL DEST. I SHOT THE VOR APCH TWICE AND MISSED BOTH TIMES. INSTEAD OF GOING TO THE ALTERNATE, I CHOSE TO RETURN TO THE PREVIOUS STOP. I HAD EASILY MADE IT IN ON THE ILS AN HR EARLIER, THE WX WAS ESSENTIALLY THE SAME, AND I WOULD HAVE A TAILWIND GOING BACK. THE DISTANCE WAS ONLY SLIGHTLY LONGER, 108 MI TO THE PREVIOUS STOP VERSES 102 MI TO THE ALTERNATE. ON THE WAY BACK, I USED THE REMAINING FUEL OUT OF THE AUX TANKS TO LEAVE AS MUCH FUEL AS POSSIBLE IN THE CTR TANK FOR THE APCH AND LNDG. THE L ENG FUEL SELECTOR WAS ON THE AUX TANK WHEN THE L ENG HESITATED. I TURNED THE L BOOST PUMP ON AND SWITCHED THE L FUEL SELECTOR BACK TO THE CTR TANK. THE ENG RAN FOR ABOUT 2 MINS AND THEN QUIT. I WENT THROUGH THE ACFT EMER PROCS, AND ALLOWED SOME TIME FOR THE L ENG TO RESTART ON THE CTR TANK. IT DID NOT. I DECLARED AN EMER AND LANDED. AFTER THE LNDG AND TAXIING TO THE RAMP, I INSPECTED THE L ENG. THERE WAS NO OBVIOUS DAMAGE TO THE ENG. I STARTED THE ENG AND DID A THOROUGH RUN UP USING THE CTR TANK FOR THE FUEL SOURCE. THE ACFT WAS ALSO INSPECTED BY MECHS. THEY PUT FUEL IN THE AUX TANKS AND PERFORMED AT LEAST 2 VERY THOROUGH RUN-UPS USING BOTH ENGS AND BOTH THE MAIN AND THE AUX TANKS AS THE FUEL SOURCE. THEY COULD NOT DUPLICATE THE PROB ON THE GND. IT IS POSSIBLE THAT I RAN THE L AUX TANK DRY. THE FLT MANUAL FOR THE ACFT SPECIFICALLY CAUTIONS THE PLT NOT TO LET THIS HAPPEN. THE FLT MANUAL ALSO STATES THAT THE TKOF AND LNDG SHOULD BE DONE WITH THE FUEL SELECTORS ON THE CTR TANK. THE HESITATION MAY HAVE BEEN CAUSED BY WATER OR SOME OTHER TYPE OF FUEL CONTAMINATION IN THE L AUX TANK. WHAT I SEE FROM THE OCCURRENCE IS JUST HOW LITTLE 45 MINS OF FUEL IS. IF I HAD MY USUAL 1 1/2 HR - 2 HR FUEL RESERVE ON BOARD, I WOULD NOT HAVE ALLOWED THE AUX TANKS TO GET ANY WHERE NEAR EMPTY. FOR THIS TRIP, IN ORDER TO HAUL ALL OF THE CARGO THE CUSTOMER WANTED TO SEND, I CHOSE TO GO WITH MINIMUM FUEL. I HAVE RELEARNED HOW IMPORTANT IT IS TO BE CONSERVATIVE IN IFR WX. IN RETROSPECT I COULD HAVE DONE SEVERAL THINGS TO MAKE THE FLT SAFER: 1) ASK THE CUSTOMER TO NOT PUT AS MUCH FREIGHT ON SO I COULD CARRY MORE FUEL. 2) ASK THE LINEMEN TO COME OUT AND FUEL THE ACFT AFTER HRS AT MY FIRST STOP. THERE WOULD HAVE BEEN A SMALL CHARGE AND POSSIBLY A DELAY. 3) WAIT FOR BETTER WX AT THE DEST.
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.