Narrative:

Fuel mismgmnt. In cruise FL350, captain noticed fuel in main tanks decreased to 1400/1100 pounds and after checking fuel panel, noticed center tank pump switches in mid position instead of on, aircraft confign with auxiliary tanks and 3 position center fuel tank switches with upper position placarded deactivated. Captain placed center tank pump switches to on position. Crew referenced QRH and operations manual for fuel imbal/center of gravity problems. Captain contacted air carrier technician to discuss potential problems. Recommended QRH procedure. Crew followed: approach with less than 1000 pounds fuel in either wing tank. Approach/landing were uneventful. Fuel on final 1350 pounds left tank, 950 pounds right tank, 7000 pounds center tank. Captain contacted air carrier postflt and was informed that no center of gravity problem existed and landing could be made with full center tank and zero fuel in mains. Cause: captain and first officer acknowledge they failed to monitor individual fuel tank quantity. Crew monitored total fuel, but let individual tank quantity to drop from scan. Contributing factors: the 3 position center tank pump switches were in the deactive position and turned 1 click to what was thought to be the on position during pushback. Also, during climb and cruise, crew was preoccupied with position reports and free text messages with dispatch concerning turbulence, to include severe turbulence reports from ATC, changing altitudes, route, etc. During the crew postflt debrief, the crew discovered the fuel level low caution light was deactivated. The crew received no warning of the low fuel condition in the wings, which normally would have illuminated at 2500 pounds in either wing tank. Supplemental information from acn 301329: crew realized their mistake and discussed at length any operation problems which may have been encountered during flight. This crew will never have a similar situation like this again to the shock effect and embarrassment of the incident. Although it is common practice for MD80 crews to keep a fuel log on the ACARS flight plan review, perhaps the company, in its debrief role, can remind crews to write down individual fuel tank quantity as well as total fuel. Also, a reminder of the 3 position fuel tank switch on aircraft with auxiliary tanks could result in an error of going from the deactive position to off versus the on position. In S80 operations manual, fuel, information is not present that the center fuel pressure low and fuel level low lights may be nonfunctional. Crew members must see the 2 STAR note in miscellaneous at the bottom of the page for this information. Recommend a change to section or an operations manual bulletin to crews which emphasizes that a crew may be in a low fuel situation without any low fuel warnings on some aircraft. Also recommend this information be addressed during flight academy S80 training. Callback conversation with reporter revealed the following information: reporter explained that his ACARS' fuel tank pump switch panel for this version of the MD80 (auxiliary tank) is slightly different from other air carrier's panels. The MD80 in question has a single switch that incorporates 3 position. The 'top' position in the 'deactivated' position. The 'center' position is the 'off' position. The 'lower' position is 'on.' in the scenario portrayed, the switch must have been in the 'deactivated' position (up), with the PIC simply reaching up to the switch and pulling down '1 click' (by personal habit) to the 'center' (off) position instead of the full down (on) position. This occurred during the pushback and engine starting sequence. The first officer is supposed to confirm, when reading the checklist, that the switch is indeed on. This was not done, PIC could not recall if this was a night operation but it was near dusk. PIC had 300 hours in this md-80 aircraft, it being his first non boeing type aircraft. The subtlety of the whole event was that the crew never had a low fuel warning (required to come 'on' at less than 2500 pounds of fuel) even though the fuel was less than 1000 pounds in either of the 2 wing tanks. He reported that he had heard of the aircraft having this type of problem before. When meeting with his air carrier he stated that he didn't know that these aircraft had the low fuel pressure and low fuel quantity warning lights deactivated. It is not evident anywhere in the pilot's handbook and was not discussed in ground school. When he stated this to the air carrier, they said that it was a simple matter of checking to see if the circuit breakers for those warning lights were 'collared' on the circuit breaker panel! That information was also not referenced anywhere in his training. Reporter made it clear that the crew fully realizes their level of culpability in the event by not keeping a fuel log as air carrier requires. But even so, this can and has happened to other crews. He would like to see the 3 position switch panel 'guard barred' in the 'deactivated' (up) position. Callback conversation with reporter acn #301329 revealed the following information: the first officer followed the captain's analysis of the incident with parallel viewpoints. He said that the fact that the overhead annunciator panel had the warning lights panel covered with a placard saying 'inoperative' did not aid the crew in their awareness of the loss of low fuel quantity/pressure warnings. They simply don't look at that area as it is a 'blank -- not operative' space. He, too, would like to see the 3 position switch panel 'guard barred' in the 'deactivated' (up) position. Either that or change the panel confign to a 2 position switch selection. He made that recommendation to the air carrier. The response from the air carrier indicated no changes were to be made, with the air carrier just reiterating the flight crew's responsibilities in their fuel logging procedures. To his knowledge, they are not going to make any changes to their reference manuals nor to their checklists as the first officer had suggested. First officer had recommended that both pilots should respond to the 'on' position of the center fuel boost pump switches. The air carrier said the checklist reader should just 'visually' affirm the responder's answer. He further suggested that the air carrier should reactivate the fuel warning system lights (no reason was given for their deactivation) or add a warning light that alerts the crew to fuel in center tank and boost pump switches not 'on.' discounting all of the preceding, he would at least like to see a posting of a warning or caution box alerting crews to the fact that on certain aircraft the warning lights are deactivated.

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Original NASA ASRS Text

Title: FLT CREW OF AN MD80 IN CRUISE MISMANAGES CENTER FUEL PUMPS, RESULTING IN LOW WING FUEL TANK LEVELS.

Narrative: FUEL MISMGMNT. IN CRUISE FL350, CAPT NOTICED FUEL IN MAIN TANKS DECREASED TO 1400/1100 LBS AND AFTER CHKING FUEL PANEL, NOTICED CTR TANK PUMP SWITCHES IN MID POS INSTEAD OF ON, ACFT CONFIGN WITH AUX TANKS AND 3 POS CTR FUEL TANK SWITCHES WITH UPPER POS PLACARDED DEACTIVATED. CAPT PLACED CTR TANK PUMP SWITCHES TO ON POS. CREW REFED QRH AND OPS MANUAL FOR FUEL IMBAL/CTR OF GRAVITY PROBS. CAPT CONTACTED ACR TECHNICIAN TO DISCUSS POTENTIAL PROBS. RECOMMENDED QRH PROC. CREW FOLLOWED: APCH WITH LESS THAN 1000 LBS FUEL IN EITHER WING TANK. APCH/LNDG WERE UNEVENTFUL. FUEL ON FINAL 1350 LBS L TANK, 950 LBS R TANK, 7000 LBS CTR TANK. CAPT CONTACTED ACR POSTFLT AND WAS INFORMED THAT NO CTR OF GRAVITY PROB EXISTED AND LNDG COULD BE MADE WITH FULL CTR TANK AND ZERO FUEL IN MAINS. CAUSE: CAPT AND FO ACKNOWLEDGE THEY FAILED TO MONITOR INDIVIDUAL FUEL TANK QUANTITY. CREW MONITORED TOTAL FUEL, BUT LET INDIVIDUAL TANK QUANTITY TO DROP FROM SCAN. CONTRIBUTING FACTORS: THE 3 POS CTR TANK PUMP SWITCHES WERE IN THE DEACTIVE POS AND TURNED 1 CLICK TO WHAT WAS THOUGHT TO BE THE ON POS DURING PUSHBACK. ALSO, DURING CLB AND CRUISE, CREW WAS PREOCCUPIED WITH POS RPTS AND FREE TEXT MESSAGES WITH DISPATCH CONCERNING TURB, TO INCLUDE SEVERE TURB RPTS FROM ATC, CHANGING ALTS, RTE, ETC. DURING THE CREW POSTFLT DEBRIEF, THE CREW DISCOVERED THE FUEL LEVEL LOW CAUTION LIGHT WAS DEACTIVATED. THE CREW RECEIVED NO WARNING OF THE LOW FUEL CONDITION IN THE WINGS, WHICH NORMALLY WOULD HAVE ILLUMINATED AT 2500 LBS IN EITHER WING TANK. SUPPLEMENTAL INFO FROM ACN 301329: CREW REALIZED THEIR MISTAKE AND DISCUSSED AT LENGTH ANY OP PROBS WHICH MAY HAVE BEEN ENCOUNTERED DURING FLT. THIS CREW WILL NEVER HAVE A SIMILAR SIT LIKE THIS AGAIN TO THE SHOCK EFFECT AND EMBARRASSMENT OF THE INCIDENT. ALTHOUGH IT IS COMMON PRACTICE FOR MD80 CREWS TO KEEP A FUEL LOG ON THE ACARS FLT PLAN REVIEW, PERHAPS THE COMPANY, IN ITS DEBRIEF ROLE, CAN REMIND CREWS TO WRITE DOWN INDIVIDUAL FUEL TANK QUANTITY AS WELL AS TOTAL FUEL. ALSO, A REMINDER OF THE 3 POS FUEL TANK SWITCH ON ACFT WITH AUX TANKS COULD RESULT IN AN ERROR OF GOING FROM THE DEACTIVE POS TO OFF VERSUS THE ON POS. IN S80 OPS MANUAL, FUEL, INFO IS NOT PRESENT THAT THE CTR FUEL PRESSURE LOW AND FUEL LEVEL LOW LIGHTS MAY BE NONFUNCTIONAL. CREW MEMBERS MUST SEE THE 2 STAR NOTE IN MISC AT THE BOTTOM OF THE PAGE FOR THIS INFO. RECOMMEND A CHANGE TO SECTION OR AN OPS MANUAL BULLETIN TO CREWS WHICH EMPHASIZES THAT A CREW MAY BE IN A LOW FUEL SIT WITHOUT ANY LOW FUEL WARNINGS ON SOME ACFT. ALSO RECOMMEND THIS INFO BE ADDRESSED DURING FLT ACADEMY S80 TRAINING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR EXPLAINED THAT HIS ACARS' FUEL TANK PUMP SWITCH PANEL FOR THIS VERSION OF THE MD80 (AUX TANK) IS SLIGHTLY DIFFERENT FROM OTHER ACR'S PANELS. THE MD80 IN QUESTION HAS A SINGLE SWITCH THAT INCORPORATES 3 POS. THE 'TOP' POS IN THE 'DEACTIVATED' POS. THE 'CTR' POS IS THE 'OFF' POS. THE 'LOWER' POS IS 'ON.' IN THE SCENARIO PORTRAYED, THE SWITCH MUST HAVE BEEN IN THE 'DEACTIVATED' POS (UP), WITH THE PIC SIMPLY REACHING UP TO THE SWITCH AND PULLING DOWN '1 CLICK' (BY PERSONAL HABIT) TO THE 'CTR' (OFF) POS INSTEAD OF THE FULL DOWN (ON) POS. THIS OCCURRED DURING THE PUSHBACK AND ENG STARTING SEQUENCE. THE FO IS SUPPOSED TO CONFIRM, WHEN READING THE CHKLIST, THAT THE SWITCH IS INDEED ON. THIS WAS NOT DONE, PIC COULD NOT RECALL IF THIS WAS A NIGHT OP BUT IT WAS NEAR DUSK. PIC HAD 300 HRS IN THIS MD-80 ACFT, IT BEING HIS FIRST NON BOEING TYPE ACFT. THE SUBTLETY OF THE WHOLE EVENT WAS THAT THE CREW NEVER HAD A LOW FUEL WARNING (REQUIRED TO COME 'ON' AT LESS THAN 2500 LBS OF FUEL) EVEN THOUGH THE FUEL WAS LESS THAN 1000 LBS IN EITHER OF THE 2 WING TANKS. HE RPTED THAT HE HAD HEARD OF THE ACFT HAVING THIS TYPE OF PROB BEFORE. WHEN MEETING WITH HIS ACR HE STATED THAT HE DIDN'T KNOW THAT THESE ACFT HAD THE LOW FUEL PRESSURE AND LOW FUEL QUANTITY WARNING LIGHTS DEACTIVATED. IT IS NOT EVIDENT ANYWHERE IN THE PLT'S HANDBOOK AND WAS NOT DISCUSSED IN GND SCHOOL. WHEN HE STATED THIS TO THE ACR, THEY SAID THAT IT WAS A SIMPLE MATTER OF CHKING TO SEE IF THE CIRCUIT BREAKERS FOR THOSE WARNING LIGHTS WERE 'COLLARED' ON THE CIRCUIT BREAKER PANEL! THAT INFO WAS ALSO NOT REFED ANYWHERE IN HIS TRAINING. RPTR MADE IT CLR THAT THE CREW FULLY REALIZES THEIR LEVEL OF CULPABILITY IN THE EVENT BY NOT KEEPING A FUEL LOG AS ACR REQUIRES. BUT EVEN SO, THIS CAN AND HAS HAPPENED TO OTHER CREWS. HE WOULD LIKE TO SEE THE 3 POS SWITCH PANEL 'GUARD BARRED' IN THE 'DEACTIVATED' (UP) POS. CALLBACK CONVERSATION WITH RPTR ACN #301329 REVEALED THE FOLLOWING INFO: THE FO FOLLOWED THE CAPT'S ANALYSIS OF THE INCIDENT WITH PARALLEL VIEWPOINTS. HE SAID THAT THE FACT THAT THE OVERHEAD ANNUNCIATOR PANEL HAD THE WARNING LIGHTS PANEL COVERED WITH A PLACARD SAYING 'INOP' DID NOT AID THE CREW IN THEIR AWARENESS OF THE LOSS OF LOW FUEL QUANTITY/PRESSURE WARNINGS. THEY SIMPLY DON'T LOOK AT THAT AREA AS IT IS A 'BLANK -- NOT OPERATIVE' SPACE. HE, TOO, WOULD LIKE TO SEE THE 3 POS SWITCH PANEL 'GUARD BARRED' IN THE 'DEACTIVATED' (UP) POS. EITHER THAT OR CHANGE THE PANEL CONFIGN TO A 2 POS SWITCH SELECTION. HE MADE THAT RECOMMENDATION TO THE ACR. THE RESPONSE FROM THE ACR INDICATED NO CHANGES WERE TO BE MADE, WITH THE ACR JUST REITERATING THE FLC'S RESPONSIBILITIES IN THEIR FUEL LOGGING PROCS. TO HIS KNOWLEDGE, THEY ARE NOT GOING TO MAKE ANY CHANGES TO THEIR REF MANUALS NOR TO THEIR CHKLISTS AS THE FO HAD SUGGESTED. FO HAD RECOMMENDED THAT BOTH PLTS SHOULD RESPOND TO THE 'ON' POS OF THE CTR FUEL BOOST PUMP SWITCHES. THE ACR SAID THE CHKLIST READER SHOULD JUST 'VISUALLY' AFFIRM THE RESPONDER'S ANSWER. HE FURTHER SUGGESTED THAT THE ACR SHOULD REACTIVATE THE FUEL WARNING SYS LIGHTS (NO REASON WAS GIVEN FOR THEIR DEACTIVATION) OR ADD A WARNING LIGHT THAT ALERTS THE CREW TO FUEL IN CTR TANK AND BOOST PUMP SWITCHES NOT 'ON.' DISCOUNTING ALL OF THE PRECEDING, HE WOULD AT LEAST LIKE TO SEE A POSTING OF A WARNING OR CAUTION BOX ALERTING CREWS TO THE FACT THAT ON CERTAIN ACFT THE WARNING LIGHTS ARE DEACTIVATED.

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.