37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 370053 |
Time | |
Date | 199705 |
Day | Tue |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : bru |
State Reference | FO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : atp pilot : cfi |
Experience | flight time last 90 days : 140 flight time total : 4200 flight time type : 390 |
ASRS Report | 370053 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I am the flight engineer on a B727 cargo aircraft. We were operating with the #3 fuel gauge placarded inoperative. Therefore, upon arrival to brussels, we have to pump all the fuel into the #2 fuel tank to obtain a known quantity, then pump a known quantity into tank #3. 3 of our own mechanics were at the aircraft and were in the process of doing this while I was performing my preflight duties. When I did my walkaround, the mechanics had the manual defueling valve open and the fueling panel opened because they were still xferring fuel. The rampers then finished loading us and I closed the cargo door and put up the tailstand, and went back into the cockpit and gave the rampers our paperwork. Then the mechanic came up into the cockpit and said he had xferred a known quantity of fuel into tank #3, that tank #3 was operating normally, that he had cleared the write-up and that the aircraft was all closed up and ready to go. He then left the cockpit, closed the forward entry door and pulled away the stairs. I did not go back outside and visually check that the 3 mechanics had closed the manual defueling valve. Upon arrival at bergamo, on my postflt, I saw the manual defueling valve was opened and realized it had been open the entire flight. I told the captain who wrote it up and one of our mechanics inspected it and cleared it. This could have been avoided if I had forced the mechanics to bring back the stairs, and visually inspected what they had been working on myself, even when it is our own mechanics. This is what I did the rest of the week after this incident and will continue to do from now on.
Original NASA ASRS Text
Title: B727 CARGO HAD THE #3 FUEL GAUGE DEFERRED. IN REFUELING NECESSARY TO XFER FUEL FROM #3 TANK TO #2 AND AFTER FUELING XFER A KNOWN AMOUNT BACK INTO #3. SO NOTED ON WALKAROUND DEFUEL VALVE OPEN. FUELERS ADVISED EVERYTHING BACK TO NORMAL AND THE FLT DEPARTED. ARR BERGAMO, ITALY, DEFUEL VALVE OPEN.
Narrative: I AM THE FE ON A B727 CARGO ACFT. WE WERE OPERATING WITH THE #3 FUEL GAUGE PLACARDED INOP. THEREFORE, UPON ARR TO BRUSSELS, WE HAVE TO PUMP ALL THE FUEL INTO THE #2 FUEL TANK TO OBTAIN A KNOWN QUANTITY, THEN PUMP A KNOWN QUANTITY INTO TANK #3. 3 OF OUR OWN MECHS WERE AT THE ACFT AND WERE IN THE PROCESS OF DOING THIS WHILE I WAS PERFORMING MY PREFLT DUTIES. WHEN I DID MY WALKAROUND, THE MECHS HAD THE MANUAL DEFUELING VALVE OPEN AND THE FUELING PANEL OPENED BECAUSE THEY WERE STILL XFERRING FUEL. THE RAMPERS THEN FINISHED LOADING US AND I CLOSED THE CARGO DOOR AND PUT UP THE TAILSTAND, AND WENT BACK INTO THE COCKPIT AND GAVE THE RAMPERS OUR PAPERWORK. THEN THE MECH CAME UP INTO THE COCKPIT AND SAID HE HAD XFERRED A KNOWN QUANTITY OF FUEL INTO TANK #3, THAT TANK #3 WAS OPERATING NORMALLY, THAT HE HAD CLRED THE WRITE-UP AND THAT THE ACFT WAS ALL CLOSED UP AND READY TO GO. HE THEN LEFT THE COCKPIT, CLOSED THE FORWARD ENTRY DOOR AND PULLED AWAY THE STAIRS. I DID NOT GO BACK OUTSIDE AND VISUALLY CHK THAT THE 3 MECHS HAD CLOSED THE MANUAL DEFUELING VALVE. UPON ARR AT BERGAMO, ON MY POSTFLT, I SAW THE MANUAL DEFUELING VALVE WAS OPENED AND REALIZED IT HAD BEEN OPEN THE ENTIRE FLT. I TOLD THE CAPT WHO WROTE IT UP AND ONE OF OUR MECHS INSPECTED IT AND CLRED IT. THIS COULD HAVE BEEN AVOIDED IF I HAD FORCED THE MECHS TO BRING BACK THE STAIRS, AND VISUALLY INSPECTED WHAT THEY HAD BEEN WORKING ON MYSELF, EVEN WHEN IT IS OUR OWN MECHS. THIS IS WHAT I DID THE REST OF THE WK AFTER THIS INCIDENT AND WILL CONTINUE TO DO FROM NOW ON.
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.