37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 300980 |
Time | |
Date | 199503 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : tlh |
State Reference | FL |
Altitude | msl bound lower : 21000 msl bound upper : 23000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zjx |
Operator | general aviation : personal |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 28 flight time total : 1210 flight time type : 4 |
ASRS Report | 300980 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : far |
Independent Detector | other other : unspecified cockpit |
Resolutory Action | flight crew : overcame equipment problem flight crew : returned to intended course or assigned course |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
At FL230 at cruise decided to switch fuel tanks from right to left when 8 gals remained. When indicator hit 8 gals I said to myself 'ok, time to switch tanks.' I was distracted by ATC and calling frequency change and WX change to partial IMC. I was concerned about icing and became distracted, thinking of evasive action, etc. I thought I had switched tanks but apparently failed to do so. Engine quit about 20 mins later, suddenly. I called ATC center and had to change several frequency at their direction. I informed them of losing altitude. I attempted immediate shift to full tank and other usual restart procedures but this was new high performance turbo charged plane and restart checklist was not easily available. Checklist at hand had only normal procedures. Delay occurred due to restart procedure being in manual, hard to dig up and out. Did restart but in ensuing chaos (bedlam) (panic) lost more altitude than necessary, about 2000 ft. Could have prevented by: 1)checklist on cruise section to say switch fuel tanks check gals in 30 mins, 2) demonstrate engine restart on chkout or close simulation, 3) scan annunciator panel more frequently, 4) stress different fuel management issues with new plane ie, I usually fly cessna's with both tanks selector for fuel selector, 5) the checklist easily available in cockpit needs to have on it restart procedure, 6) keep my composure and less panic next time - how to have checklist practice more emergency procedures with chkout, no mention of it on checklist, 7) oxygen mask didn't have microphone so communication with other boom microphone - may have led to hypoxia with emergency communication and not replacing mask firmly on face!
Original NASA ASRS Text
Title: RPTR, SINGLE PLT AT HIGH ALT, SINGLE ENG QUIT.
Narrative: AT FL230 AT CRUISE DECIDED TO SWITCH FUEL TANKS FROM R TO L WHEN 8 GALS REMAINED. WHEN INDICATOR HIT 8 GALS I SAID TO MYSELF 'OK, TIME TO SWITCH TANKS.' I WAS DISTRACTED BY ATC AND CALLING FREQ CHANGE AND WX CHANGE TO PARTIAL IMC. I WAS CONCERNED ABOUT ICING AND BECAME DISTRACTED, THINKING OF EVASIVE ACTION, ETC. I THOUGHT I HAD SWITCHED TANKS BUT APPARENTLY FAILED TO DO SO. ENG QUIT ABOUT 20 MINS LATER, SUDDENLY. I CALLED ATC CTR AND HAD TO CHANGE SEVERAL FREQ AT THEIR DIRECTION. I INFORMED THEM OF LOSING ALT. I ATTEMPTED IMMEDIATE SHIFT TO FULL TANK AND OTHER USUAL RESTART PROCS BUT THIS WAS NEW HIGH PERFORMANCE TURBO CHARGED PLANE AND RESTART CHKLIST WAS NOT EASILY AVAILABLE. CHKLIST AT HAND HAD ONLY NORMAL PROCS. DELAY OCCURRED DUE TO RESTART PROC BEING IN MANUAL, HARD TO DIG UP AND OUT. DID RESTART BUT IN ENSUING CHAOS (BEDLAM) (PANIC) LOST MORE ALT THAN NECESSARY, ABOUT 2000 FT. COULD HAVE PREVENTED BY: 1)CHKLIST ON CRUISE SECTION TO SAY SWITCH FUEL TANKS CHK GALS IN 30 MINS, 2) DEMONSTRATE ENG RESTART ON CHKOUT OR CLOSE SIMULATION, 3) SCAN ANNUNCIATOR PANEL MORE FREQUENTLY, 4) STRESS DIFFERENT FUEL MGMNT ISSUES WITH NEW PLANE IE, I USUALLY FLY CESSNA'S WITH BOTH TANKS SELECTOR FOR FUEL SELECTOR, 5) THE CHKLIST EASILY AVAILABLE IN COCKPIT NEEDS TO HAVE ON IT RESTART PROC, 6) KEEP MY COMPOSURE AND LESS PANIC NEXT TIME - HOW TO HAVE CHKLIST PRACTICE MORE EMER PROCS WITH CHKOUT, NO MENTION OF IT ON CHKLIST, 7) OXYGEN MASK DIDN'T HAVE MIKE SO COM WITH OTHER BOOM MIKE - MAY HAVE LED TO HYPOXIA WITH EMER COM AND NOT REPLACING MASK FIRMLY ON FACE!
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.