37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 379320 |
Time | |
Date | 199709 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bos |
State Reference | MA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff cruise other ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : cfi pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 13000 flight time type : 3800 |
ASRS Report | 379320 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : instrument pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 250 flight time total : 6000 flight time type : 500 |
ASRS Report | 379493 |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Dispatch minimum fuel for bos-dtw 28600 pounds with mbi, mi, for alternate requiring 4600 pounds, plus 33 mins contingency fuel for en route/approach deviations/delays was 3900 pounds. Departed gate in bos with 23800 pounds. WX in dtw VFR, deleted alternate and landed with legal fuel in dtw. Missed error on checklist before start. So heard the 8 in 28.6, captain heard 8 in 23.8, both thought correct fuel load was on board. First officer normally loads fuel in ACARS flight data page but so had already entered it, so another possible check was missed. Complacency no doubt played a large part, as flight plans, fueling, wind information, etc, normally is excellent. (Jump seater in cockpit may have contributed slightly with introductions, etc, before departure, no fault of his.) problem arose when dispatch added more fuel on flight plan (second release) and bos station operations and fueler did not put on additional fuel. Cause: complacency by all involved. Solution: every phase of flight or ground operations by the book, very carefully checking and rechking. Supplemental information from acn 379493: dispatch release #1 was for 23700 pounds fuel, #2 release increased this by 5000 pounds to 28600 pounds. The so entered the fuel data into the ACARS unit. That's something that I normally do and xchk against the release fuel. Bottom line is that after 2 long days and minimum rest, we, as a crew and as 3 individuals, became complacent. I heard the '8' and heard what I wanted to hear. The 5000 pounds additional was added for possible en route WX which never materialized. I failed to mention how the problem was discovered. The so discovered the shortage during the first fuel check in-flight. We then went back and put the pieces together. Supplemental information from acn 379504: I arrived to the cockpit earlier than the rest of the crew to perform my preflight duties. The release was not available to me yet (which is not unusual at this point) so I performed my fuel quantities check and reasonableness checks using the fueler receipt which is placed on the so desk after fueling is complete. The dispatched load on the receipt was 23800 pounds. My checks agreed. I later failed to check the release fuel when the release became available to me against the fuel receipt.
Original NASA ASRS Text
Title: B727 CREW DEPARTS BOS WITH LESS FUEL THAN THEIR REVISED COMPANY RELEASE REQUIRES. RPTRS CITE MULTIPLE FACTORS OF LACK OF GND PERSONNEL COORD DURING GND REFUELING PROC, COMPLACENCY, FAILED COCKPIT CHKS, FATIGUE AND FLC DISTR DURING COCKPIT SET UP.
Narrative: DISPATCH MINIMUM FUEL FOR BOS-DTW 28600 LBS WITH MBI, MI, FOR ALTERNATE REQUIRING 4600 LBS, PLUS 33 MINS CONTINGENCY FUEL FOR ENRTE/APCH DEVS/DELAYS WAS 3900 LBS. DEPARTED GATE IN BOS WITH 23800 LBS. WX IN DTW VFR, DELETED ALTERNATE AND LANDED WITH LEGAL FUEL IN DTW. MISSED ERROR ON CHKLIST BEFORE START. SO HEARD THE 8 IN 28.6, CAPT HEARD 8 IN 23.8, BOTH THOUGHT CORRECT FUEL LOAD WAS ON BOARD. FO NORMALLY LOADS FUEL IN ACARS FLT DATA PAGE BUT SO HAD ALREADY ENTERED IT, SO ANOTHER POSSIBLE CHK WAS MISSED. COMPLACENCY NO DOUBT PLAYED A LARGE PART, AS FLT PLANS, FUELING, WIND INFO, ETC, NORMALLY IS EXCELLENT. (JUMP SEATER IN COCKPIT MAY HAVE CONTRIBUTED SLIGHTLY WITH INTRODUCTIONS, ETC, BEFORE DEP, NO FAULT OF HIS.) PROB AROSE WHEN DISPATCH ADDED MORE FUEL ON FLT PLAN (SECOND RELEASE) AND BOS STATION OPS AND FUELER DID NOT PUT ON ADDITIONAL FUEL. CAUSE: COMPLACENCY BY ALL INVOLVED. SOLUTION: EVERY PHASE OF FLT OR GND OPS BY THE BOOK, VERY CAREFULLY CHKING AND RECHKING. SUPPLEMENTAL INFO FROM ACN 379493: DISPATCH RELEASE #1 WAS FOR 23700 LBS FUEL, #2 RELEASE INCREASED THIS BY 5000 LBS TO 28600 LBS. THE SO ENTERED THE FUEL DATA INTO THE ACARS UNIT. THAT'S SOMETHING THAT I NORMALLY DO AND XCHK AGAINST THE RELEASE FUEL. BOTTOM LINE IS THAT AFTER 2 LONG DAYS AND MINIMUM REST, WE, AS A CREW AND AS 3 INDIVIDUALS, BECAME COMPLACENT. I HEARD THE '8' AND HEARD WHAT I WANTED TO HEAR. THE 5000 LBS ADDITIONAL WAS ADDED FOR POSSIBLE ENRTE WX WHICH NEVER MATERIALIZED. I FAILED TO MENTION HOW THE PROB WAS DISCOVERED. THE SO DISCOVERED THE SHORTAGE DURING THE FIRST FUEL CHK INFLT. WE THEN WENT BACK AND PUT THE PIECES TOGETHER. SUPPLEMENTAL INFO FROM ACN 379504: I ARRIVED TO THE COCKPIT EARLIER THAN THE REST OF THE CREW TO PERFORM MY PREFLT DUTIES. THE RELEASE WAS NOT AVAILABLE TO ME YET (WHICH IS NOT UNUSUAL AT THIS POINT) SO I PERFORMED MY FUEL QUANTITIES CHK AND REASONABLENESS CHKS USING THE FUELER RECEIPT WHICH IS PLACED ON THE SO DESK AFTER FUELING IS COMPLETE. THE DISPATCHED LOAD ON THE RECEIPT WAS 23800 LBS. MY CHKS AGREED. I LATER FAILED TO CHK THE RELEASE FUEL WHEN THE RELEASE BECAME AVAILABLE TO ME AGAINST THE FUEL RECEIPT.
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.