Narrative:

On feb/thu/96, at around XX30 hours we took off at slc en route to bur. This was the fifth leg of the day. We earlier had a bird strike. We didn't think this was a problem, and fueled this aircraft for the above flight. We also called the mechanics to clean the wing of the bird strike, and check for damage. They later informed us the leading edge was flattened, exceeding the one quarter inch damage requiring the aircraft to be pulled off line for inspection. The new aircraft came over from the hangar, arriving at the gate at about XX44. We were due to depart at XX50. Everyone was hurrying, but I did not feel hurried. I was just trying to get things done in an efficient way, and get moving in a reasonable time. It ended up that we did not get the new aircraft fueled. We also missed the lack of fuel on the prestart checklist. We lifted off for bur with less than the required dispatch fuel. It has always been my practice to pick up the dispatch release in operations before the flight, checking things like WX and fuel required before I go out to the aircraft. Usually there is a fueler in operations to get the fuel load for each flight, and then either fuel the aircraft himself or radio to another fueler the fuel load for each flight. The second fueler then fuels the aircraft. Also, the copilot usually gets the fuel load before going out to the aircraft, checks to make sure it is correctly fueled and all fuel doors are closed. On the engine start checklist we have an item: 'fuel pumps, xflow, qty.' my response is 'on, checked, and the fuel on board (in this case stated as '8600 pounds').' we know we did this checklist, I even remember doing the above stated items. I don't know if I got interrupted stating the quantity, if I missed it completely, if I read it wrong and stated what I knew was the correct amount, if I stated the wrong amount and thought nothing of it. My copilot says he remembers me stating the correct amount. He also remembers not thinking about fuel after the aircraft switch until this checklist, and not again until I discovered the problem in-flight. A couple possibilities are: 1) when this flight attendant closed the main cabin door she verbally asks if the door is closed. If she did this in the middle of the checklist right when I was to look at fuel quantity, I may have missed it because of responding to her. This has happened many times in the past and I have not missed it. 2) when I picked up the original and the new release (due to the aircraft switch) I saw the fuel was 8600 pounds. I was sure of the fuel. If I am not sure of the fuel it is my personal habit to check the release when we get to 'fuel pumps, xflow, qty' to make sure we have the correct amount of fuel. I was sure this time so just stated the fuel. We could have had more like 5600 pounds and I misread it as 8600 pounds. In any case we didn't have the correct amount of fuel on board, and took off in this condition. During the climb out of slc I noticed the fuel was lower than it should be. I would guess we were about 100 NM south of slc and between 25000-29000 ft. I immediately told my copilot. We realized instead of trying how to figure out how it happened we should review our options. They included items such as: checking the dispatch release fuel required for the trip (8600 pounds) and how much contingency fuel this included (I don't remember this but is usually about 2000 pounds), how much fuel we had for 45 min reserve (also just over 2000 pounds), we didn't have or need alternate fuel, we figured the fuel we started with by adding fuel remaining to fuel burned (probably between 5400 pounds and 5600 pounds) at start of taxi, we looked at our present fuel flow and the time remaining to bur to determine our remaining fuel upon landing, we looked at present and forecast WX including present headwinds (in the teens at that time). We decided we could make it to bur with about 1300 pounds remaining, not enough for normal IFR reserves but under ideal conditions acceptable. My copilot and I discussed this and decided to make a decision approaching las. The headwinds did pick up to about 60 KT headwind component, we were concerned about ATC wanting us to start down early like they always do (which would result in higher fuel consumption), about having to circle to land in bur because of the winds out of the north and forecast to be (meaning we probably couldn't do a straight in to runway 15), about any other contingencies that may come about that we didn't have the fuel and therefore the time to deal with. My copilot was the first one to say let's land in las, I immediately told him that was the best thing and to notify ATC, company, the flight attendant and passenger. We made an uneventful landing with plenty of fuel remaining (about 2700 pounds). We felt we did the right thing even though it made notice of our error. We got fuel, a new release and manifest in las and continued to bur. I think fatigue plays a role in errors of this sort. This month I do the same 4 day trip every week. As I commute my first day is always a 19 hour day. My last day has also been a long day because my airline has canceled the flight home and I choose to drive home instead of spending yet another night in a motel room (this is expensive and I already spend most of my life in motels). 2 weeks ago our flight attendant for the month got the flu and I did last week. I think my schedules including the commute resulting in excessively long days, contributed to this. I spent one of my days off in bed, and while still a little weak thought I was fit for duty. I had been up about 16 hours when the above occurrence took place. My copilot had worked 6 days with one off just before this happened. On his last overnight he didn't sleep well because storms knocked out the electricity and the room was very cold. These are short term problems that can't really be avoided. I believe long term schedules can also wear down an individual to where he doesn't perform as well. I have been in this airplane 2 yrs. I decided to become a jet pilot and the extra pay would be nice. I didn't know how the schedules would turn out. Probably 90% of those 24 months I worked 5 on and 2 days off. At least several of the months I had to commute to and from work on my days off. This leaves no time to relax. I like summer activities like camping. Numerous times I have asked for time off (sometimes months in advance) and can almost never get it because we never have enough crews to cover the shifts. We become locked in an aircraft and can't easily switch for better schedules. A lot of our schedules get done late at night and start early the next day (8 hour overnights). Also, pilots are getting into trouble left and right for doing minor things wrong. Punishment as a way of dealing with human error increases stress which increases the chance of more errors. It is difficult to leave a job (source of income, maybe a fair amount of seniority) due to these kinds of factors, that's why we accept things the way they are.

Google
 

Original NASA ASRS Text

Title: LAST MIN ACFT CHANGE, EVERYONE RUSHING TO MEET SCHEDULED DEP, FLC AND COMPANY FAILED TO FUEL ACFT ADEQUATELY. ENRTE FUELING STOP.

Narrative: ON FEB/THU/96, AT AROUND XX30 HRS WE TOOK OFF AT SLC ENRTE TO BUR. THIS WAS THE FIFTH LEG OF THE DAY. WE EARLIER HAD A BIRD STRIKE. WE DIDN'T THINK THIS WAS A PROB, AND FUELED THIS ACFT FOR THE ABOVE FLT. WE ALSO CALLED THE MECHS TO CLEAN THE WING OF THE BIRD STRIKE, AND CHK FOR DAMAGE. THEY LATER INFORMED US THE LEADING EDGE WAS FLATTENED, EXCEEDING THE ONE QUARTER INCH DAMAGE REQUIRING THE ACFT TO BE PULLED OFF LINE FOR INSPECTION. THE NEW ACFT CAME OVER FROM THE HANGAR, ARRIVING AT THE GATE AT ABOUT XX44. WE WERE DUE TO DEPART AT XX50. EVERYONE WAS HURRYING, BUT I DID NOT FEEL HURRIED. I WAS JUST TRYING TO GET THINGS DONE IN AN EFFICIENT WAY, AND GET MOVING IN A REASONABLE TIME. IT ENDED UP THAT WE DID NOT GET THE NEW ACFT FUELED. WE ALSO MISSED THE LACK OF FUEL ON THE PRESTART CHKLIST. WE LIFTED OFF FOR BUR WITH LESS THAN THE REQUIRED DISPATCH FUEL. IT HAS ALWAYS BEEN MY PRACTICE TO PICK UP THE DISPATCH RELEASE IN OPS BEFORE THE FLT, CHKING THINGS LIKE WX AND FUEL REQUIRED BEFORE I GO OUT TO THE ACFT. USUALLY THERE IS A FUELER IN OPS TO GET THE FUEL LOAD FOR EACH FLT, AND THEN EITHER FUEL THE ACFT HIMSELF OR RADIO TO ANOTHER FUELER THE FUEL LOAD FOR EACH FLT. THE SECOND FUELER THEN FUELS THE ACFT. ALSO, THE COPLT USUALLY GETS THE FUEL LOAD BEFORE GOING OUT TO THE ACFT, CHKS TO MAKE SURE IT IS CORRECTLY FUELED AND ALL FUEL DOORS ARE CLOSED. ON THE ENG START CHKLIST WE HAVE AN ITEM: 'FUEL PUMPS, XFLOW, QTY.' MY RESPONSE IS 'ON, CHKED, AND THE FUEL ON BOARD (IN THIS CASE STATED AS '8600 LBS').' WE KNOW WE DID THIS CHKLIST, I EVEN REMEMBER DOING THE ABOVE STATED ITEMS. I DON'T KNOW IF I GOT INTERRUPTED STATING THE QUANTITY, IF I MISSED IT COMPLETELY, IF I READ IT WRONG AND STATED WHAT I KNEW WAS THE CORRECT AMOUNT, IF I STATED THE WRONG AMOUNT AND THOUGHT NOTHING OF IT. MY COPLT SAYS HE REMEMBERS ME STATING THE CORRECT AMOUNT. HE ALSO REMEMBERS NOT THINKING ABOUT FUEL AFTER THE ACFT SWITCH UNTIL THIS CHKLIST, AND NOT AGAIN UNTIL I DISCOVERED THE PROB INFLT. A COUPLE POSSIBILITIES ARE: 1) WHEN THIS FLT ATTENDANT CLOSED THE MAIN CABIN DOOR SHE VERBALLY ASKS IF THE DOOR IS CLOSED. IF SHE DID THIS IN THE MIDDLE OF THE CHKLIST RIGHT WHEN I WAS TO LOOK AT FUEL QUANTITY, I MAY HAVE MISSED IT BECAUSE OF RESPONDING TO HER. THIS HAS HAPPENED MANY TIMES IN THE PAST AND I HAVE NOT MISSED IT. 2) WHEN I PICKED UP THE ORIGINAL AND THE NEW RELEASE (DUE TO THE ACFT SWITCH) I SAW THE FUEL WAS 8600 LBS. I WAS SURE OF THE FUEL. IF I AM NOT SURE OF THE FUEL IT IS MY PERSONAL HABIT TO CHK THE RELEASE WHEN WE GET TO 'FUEL PUMPS, XFLOW, QTY' TO MAKE SURE WE HAVE THE CORRECT AMOUNT OF FUEL. I WAS SURE THIS TIME SO JUST STATED THE FUEL. WE COULD HAVE HAD MORE LIKE 5600 LBS AND I MISREAD IT AS 8600 LBS. IN ANY CASE WE DIDN'T HAVE THE CORRECT AMOUNT OF FUEL ON BOARD, AND TOOK OFF IN THIS CONDITION. DURING THE CLBOUT OF SLC I NOTICED THE FUEL WAS LOWER THAN IT SHOULD BE. I WOULD GUESS WE WERE ABOUT 100 NM S OF SLC AND BTWN 25000-29000 FT. I IMMEDIATELY TOLD MY COPLT. WE REALIZED INSTEAD OF TRYING HOW TO FIGURE OUT HOW IT HAPPENED WE SHOULD REVIEW OUR OPTIONS. THEY INCLUDED ITEMS SUCH AS: CHKING THE DISPATCH RELEASE FUEL REQUIRED FOR THE TRIP (8600 LBS) AND HOW MUCH CONTINGENCY FUEL THIS INCLUDED (I DON'T REMEMBER THIS BUT IS USUALLY ABOUT 2000 LBS), HOW MUCH FUEL WE HAD FOR 45 MIN RESERVE (ALSO JUST OVER 2000 LBS), WE DIDN'T HAVE OR NEED ALTERNATE FUEL, WE FIGURED THE FUEL WE STARTED WITH BY ADDING FUEL REMAINING TO FUEL BURNED (PROBABLY BTWN 5400 LBS AND 5600 LBS) AT START OF TAXI, WE LOOKED AT OUR PRESENT FUEL FLOW AND THE TIME REMAINING TO BUR TO DETERMINE OUR REMAINING FUEL UPON LNDG, WE LOOKED AT PRESENT AND FORECAST WX INCLUDING PRESENT HEADWINDS (IN THE TEENS AT THAT TIME). WE DECIDED WE COULD MAKE IT TO BUR WITH ABOUT 1300 LBS REMAINING, NOT ENOUGH FOR NORMAL IFR RESERVES BUT UNDER IDEAL CONDITIONS ACCEPTABLE. MY COPLT AND I DISCUSSED THIS AND DECIDED TO MAKE A DECISION APCHING LAS. THE HEADWINDS DID PICK UP TO ABOUT 60 KT HEADWIND COMPONENT, WE WERE CONCERNED ABOUT ATC WANTING US TO START DOWN EARLY LIKE THEY ALWAYS DO (WHICH WOULD RESULT IN HIGHER FUEL CONSUMPTION), ABOUT HAVING TO CIRCLE TO LAND IN BUR BECAUSE OF THE WINDS OUT OF THE N AND FORECAST TO BE (MEANING WE PROBABLY COULDN'T DO A STRAIGHT IN TO RWY 15), ABOUT ANY OTHER CONTINGENCIES THAT MAY COME ABOUT THAT WE DIDN'T HAVE THE FUEL AND THEREFORE THE TIME TO DEAL WITH. MY COPLT WAS THE FIRST ONE TO SAY LET'S LAND IN LAS, I IMMEDIATELY TOLD HIM THAT WAS THE BEST THING AND TO NOTIFY ATC, COMPANY, THE FLT ATTENDANT AND PAX. WE MADE AN UNEVENTFUL LNDG WITH PLENTY OF FUEL REMAINING (ABOUT 2700 LBS). WE FELT WE DID THE RIGHT THING EVEN THOUGH IT MADE NOTICE OF OUR ERROR. WE GOT FUEL, A NEW RELEASE AND MANIFEST IN LAS AND CONTINUED TO BUR. I THINK FATIGUE PLAYS A ROLE IN ERRORS OF THIS SORT. THIS MONTH I DO THE SAME 4 DAY TRIP EVERY WK. AS I COMMUTE MY FIRST DAY IS ALWAYS A 19 HR DAY. MY LAST DAY HAS ALSO BEEN A LONG DAY BECAUSE MY AIRLINE HAS CANCELED THE FLT HOME AND I CHOOSE TO DRIVE HOME INSTEAD OF SPENDING YET ANOTHER NIGHT IN A MOTEL ROOM (THIS IS EXPENSIVE AND I ALREADY SPEND MOST OF MY LIFE IN MOTELS). 2 WKS AGO OUR FLT ATTENDANT FOR THE MONTH GOT THE FLU AND I DID LAST WK. I THINK MY SCHEDULES INCLUDING THE COMMUTE RESULTING IN EXCESSIVELY LONG DAYS, CONTRIBUTED TO THIS. I SPENT ONE OF MY DAYS OFF IN BED, AND WHILE STILL A LITTLE WEAK THOUGHT I WAS FIT FOR DUTY. I HAD BEEN UP ABOUT 16 HRS WHEN THE ABOVE OCCURRENCE TOOK PLACE. MY COPLT HAD WORKED 6 DAYS WITH ONE OFF JUST BEFORE THIS HAPPENED. ON HIS LAST OVERNIGHT HE DIDN'T SLEEP WELL BECAUSE STORMS KNOCKED OUT THE ELECTRICITY AND THE ROOM WAS VERY COLD. THESE ARE SHORT TERM PROBS THAT CAN'T REALLY BE AVOIDED. I BELIEVE LONG TERM SCHEDULES CAN ALSO WEAR DOWN AN INDIVIDUAL TO WHERE HE DOESN'T PERFORM AS WELL. I HAVE BEEN IN THIS AIRPLANE 2 YRS. I DECIDED TO BECOME A JET PLT AND THE EXTRA PAY WOULD BE NICE. I DIDN'T KNOW HOW THE SCHEDULES WOULD TURN OUT. PROBABLY 90% OF THOSE 24 MONTHS I WORKED 5 ON AND 2 DAYS OFF. AT LEAST SEVERAL OF THE MONTHS I HAD TO COMMUTE TO AND FROM WORK ON MY DAYS OFF. THIS LEAVES NO TIME TO RELAX. I LIKE SUMMER ACTIVITIES LIKE CAMPING. NUMEROUS TIMES I HAVE ASKED FOR TIME OFF (SOMETIMES MONTHS IN ADVANCE) AND CAN ALMOST NEVER GET IT BECAUSE WE NEVER HAVE ENOUGH CREWS TO COVER THE SHIFTS. WE BECOME LOCKED IN AN ACFT AND CAN'T EASILY SWITCH FOR BETTER SCHEDULES. A LOT OF OUR SCHEDULES GET DONE LATE AT NIGHT AND START EARLY THE NEXT DAY (8 HR OVERNIGHTS). ALSO, PLTS ARE GETTING INTO TROUBLE LEFT AND RIGHT FOR DOING MINOR THINGS WRONG. PUNISHMENT AS A WAY OF DEALING WITH HUMAN ERROR INCREASES STRESS WHICH INCREASES THE CHANCE OF MORE ERRORS. IT IS DIFFICULT TO LEAVE A JOB (SOURCE OF INCOME, MAYBE A FAIR AMOUNT OF SENIORITY) DUE TO THESE KINDS OF FACTORS, THAT'S WHY WE ACCEPT THINGS THE WAY THEY ARE.

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.