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|
Attributes | |
ACN | 355740 |
Time | |
Date | 199612 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mia |
State Reference | FL |
Altitude | msl bound lower : 7000 msl bound upper : 7000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : mia artcc : zse |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude climbout : takeoff ground : preflight |
Route In Use | departure other enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 3950 flight time type : 750 |
ASRS Report | 355740 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 210 flight time total : 850 flight time type : 210 |
ASRS Report | 355481 |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During a quick turnaround in miami, I was helping a couple of passenger into the gate area while the aircraft was being svced. The first officer was to oversee the refueling, while obtaining the clearance and filling out the weight and balance. Upon returning to the plane, we performed a quick pre-engine start checklist and departed. Approximately 10 mins after departure from mia, I looked up at the fuel gauges and realized we never got fueled in mia, and that we had insufficient fuel to get to our destination. Therefore, we returned to mia to refuel. I believe some of the factors contributing to this incident were: fatigue and rushing for time. I had worked 6 days in a row, had 1 day off, and this was my first day back to work. We had already flown 5 hours that day, and it was getting late in the evening. Both of us were getting tired, and this was to be our last round trip of the night. We were rushing to get the flight out on time, since the scheduled departure time was 10 mins after we had arrived from the previous trip. During our rush, we must have missed an item on the prestart checklist that would have told us our fuel state was below that required for dispatch. Although the fuel level was never unsafe, and was enough for over an hour flying time, it would not have gotten us to our destination. In summary, fatigue from a busy work schedule and rushing during a quick turnaround were the prime contributors to this incident. Supplemental information from acn 355481: about 1 hour behind schedule, we just landed and operations told us to hurry up, we were almost 1 hour late. We shut down the engines and we saw the fuel truck stopping under the wing. At that time, the captain left the airplane to do his things and I started with my paperwork (weight and balance and clearance). I saw the fuel truck and I set the desired fuel quantity on the fuel totalizer. When I was finishing my paperwork, all the crew members got into the airplane saying 'let's go, hurry up, we have to go,' and like usual, I thought the captain had the fuel receipt as usual and like I saw the fuel truck and personnel, I assumed we were refueled. The captain thought I had the receipt, but looks like none of us had it. Like everybody was pushing us, and we were tired and late, we made a big mistake, we ran the turnaround checks really fast and we failed to check the fuel gauges. We both thought we had fuel, but we made 2 mistakes -- first, no communication. Second, we assumed we had fuel because we saw everything like always and I set the fuel totalizer with no fuel on board, and I did it without checking it because of the hurry. Without checking the checklist because we were in a hurry and like he had done that hundreds of times, he started the engines without asking for the proper checklist. When we were doing the climb checks we saw the gauges and we decided to go back for more fuel.
Original NASA ASRS Text
Title: RETURN LAND MANDATED BY FLC DEV FROM RAMP OP GND REFUELING PROC. FUEL REQUIRED WAS DEEMED INADEQUATE DURING CLB CHKLIST USE. NIGHT OP.
Narrative: DURING A QUICK TURNAROUND IN MIAMI, I WAS HELPING A COUPLE OF PAX INTO THE GATE AREA WHILE THE ACFT WAS BEING SVCED. THE FO WAS TO OVERSEE THE REFUELING, WHILE OBTAINING THE CLRNC AND FILLING OUT THE WT AND BAL. UPON RETURNING TO THE PLANE, WE PERFORMED A QUICK PRE-ENG START CHKLIST AND DEPARTED. APPROX 10 MINS AFTER DEP FROM MIA, I LOOKED UP AT THE FUEL GAUGES AND REALIZED WE NEVER GOT FUELED IN MIA, AND THAT WE HAD INSUFFICIENT FUEL TO GET TO OUR DEST. THEREFORE, WE RETURNED TO MIA TO REFUEL. I BELIEVE SOME OF THE FACTORS CONTRIBUTING TO THIS INCIDENT WERE: FATIGUE AND RUSHING FOR TIME. I HAD WORKED 6 DAYS IN A ROW, HAD 1 DAY OFF, AND THIS WAS MY FIRST DAY BACK TO WORK. WE HAD ALREADY FLOWN 5 HRS THAT DAY, AND IT WAS GETTING LATE IN THE EVENING. BOTH OF US WERE GETTING TIRED, AND THIS WAS TO BE OUR LAST ROUND TRIP OF THE NIGHT. WE WERE RUSHING TO GET THE FLT OUT ON TIME, SINCE THE SCHEDULED DEP TIME WAS 10 MINS AFTER WE HAD ARRIVED FROM THE PREVIOUS TRIP. DURING OUR RUSH, WE MUST HAVE MISSED AN ITEM ON THE PRESTART CHKLIST THAT WOULD HAVE TOLD US OUR FUEL STATE WAS BELOW THAT REQUIRED FOR DISPATCH. ALTHOUGH THE FUEL LEVEL WAS NEVER UNSAFE, AND WAS ENOUGH FOR OVER AN HR FLYING TIME, IT WOULD NOT HAVE GOTTEN US TO OUR DEST. IN SUMMARY, FATIGUE FROM A BUSY WORK SCHEDULE AND RUSHING DURING A QUICK TURNAROUND WERE THE PRIME CONTRIBUTORS TO THIS INCIDENT. SUPPLEMENTAL INFO FROM ACN 355481: ABOUT 1 HR BEHIND SCHEDULE, WE JUST LANDED AND OPS TOLD US TO HURRY UP, WE WERE ALMOST 1 HR LATE. WE SHUT DOWN THE ENGS AND WE SAW THE FUEL TRUCK STOPPING UNDER THE WING. AT THAT TIME, THE CAPT LEFT THE AIRPLANE TO DO HIS THINGS AND I STARTED WITH MY PAPERWORK (WT AND BAL AND CLRNC). I SAW THE FUEL TRUCK AND I SET THE DESIRED FUEL QUANTITY ON THE FUEL TOTALIZER. WHEN I WAS FINISHING MY PAPERWORK, ALL THE CREW MEMBERS GOT INTO THE AIRPLANE SAYING 'LET'S GO, HURRY UP, WE HAVE TO GO,' AND LIKE USUAL, I THOUGHT THE CAPT HAD THE FUEL RECEIPT AS USUAL AND LIKE I SAW THE FUEL TRUCK AND PERSONNEL, I ASSUMED WE WERE REFUELED. THE CAPT THOUGHT I HAD THE RECEIPT, BUT LOOKS LIKE NONE OF US HAD IT. LIKE EVERYBODY WAS PUSHING US, AND WE WERE TIRED AND LATE, WE MADE A BIG MISTAKE, WE RAN THE TURNAROUND CHKS REALLY FAST AND WE FAILED TO CHK THE FUEL GAUGES. WE BOTH THOUGHT WE HAD FUEL, BUT WE MADE 2 MISTAKES -- FIRST, NO COM. SECOND, WE ASSUMED WE HAD FUEL BECAUSE WE SAW EVERYTHING LIKE ALWAYS AND I SET THE FUEL TOTALIZER WITH NO FUEL ON BOARD, AND I DID IT WITHOUT CHKING IT BECAUSE OF THE HURRY. WITHOUT CHKING THE CHKLIST BECAUSE WE WERE IN A HURRY AND LIKE HE HAD DONE THAT HUNDREDS OF TIMES, HE STARTED THE ENGS WITHOUT ASKING FOR THE PROPER CHKLIST. WHEN WE WERE DOING THE CLB CHKS WE SAW THE GAUGES AND WE DECIDED TO GO BACK FOR MORE FUEL.
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.