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|
Attributes | |
ACN | 392570 |
Time | |
Date | 199801 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : mzz |
State Reference | IN |
Altitude | msl bound lower : 17000 msl bound upper : 17000 |
Environment | |
Flight Conditions | IMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zid |
Operator | common carrier : air carrier |
Make Model Name | SF 340A |
Operating Under FAR Part | Part 135 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : cfi pilot : atp pilot : instrument |
Experience | flight time last 90 days : 240 flight time total : 5000 flight time type : 500 |
ASRS Report | 392570 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure |
Independent Detector | other flight crewa other other : unspecified cockpit |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
The mistake was actually made on the ground in evv, in. The information above is when it was actually discovered. The flight into evv was early, it gave the crew a chance to go into the terminal, stretch our legs and walk around. In essence no one was in a hurry. Checklist were read (items checked) and the fuel load was agreed to by both pilots. There may have been some 'see what you want to see' and 'expentancy factor' involved. I walked around the airplane before we departed. Before we read the checklist, the first officer noted he had adjusted the fuel load to 3800 pounds on the load control form because 3700 pounds had been written in and we were over svced by approximately 100 pounds. At this point we read the checklist, agreed on 3800 pounds with a minimum fuel requirement of 3572 pounds and a recommmended fuel of 3617 pounds. At this point I was probably predisposed to seeing 3800 pounds. What we really had was 2800 pounds and change, that we had flown in with. To the company's credit our release and estimated fuel burns have been improved greatly over the last couple of yrs. Included with the release is a detailed print-out containing the majority of en route fixes, ete's, mileage's, TAS, GS, temperatures, fuel used and fuel remaining. I believed so much that I had 3800 pounds when I started that at the first few check points I was still misinterpolating the gauges and believed they agreed with the fuel breakdown. It wasn't until we reached mzz that I found the mistake. The gauges were very close to the 'labeled' 1000 pounds mark on each gauge. No interpolation required. I immediately knew what happened. The truck never showed. Unlike the last company I worked for, no one seems to be auditing the fuel put on board at each fueling with what should have been put on board, based on the previous flts remaining fuel. Discussing this with my peers, they related similar occurrences -- some reported, some not -- in almost all but the most severe cases where the airplane had to immediately return to the departure airport, the problem was not discovered until reaching the destination, where the crew fills in the airplane logs, which require flight time and fuel used to be entered. I believe the log helped me identify the mistake much earlier than if I hadn't been using it. The problem is more prevalent than I ever imagined -- talking to all the pilots who have either done it or almost did it. In the back of my mind, I keep hearing, 'what if I needed that fuel?' callback conversation with reporter revealed the following information: the reporter said it was the crew's idea the aircraft was already fueled and they misread the fuel quantity indicators. The reporter said the company does not issue fuel slips filled out by the fueler with the pounds and gals added from the truck meter.
Original NASA ASRS Text
Title: A SAAB 340 WAS DISPATCHED WITH A FUEL LOAD 1000 LBS LOWER THAN REQUIRED ON THE DISPATCH RELEASE AND THE CREW MISREAD THE FUEL QUANTITY INDICATORS.
Narrative: THE MISTAKE WAS ACTUALLY MADE ON THE GND IN EVV, IN. THE INFO ABOVE IS WHEN IT WAS ACTUALLY DISCOVERED. THE FLT INTO EVV WAS EARLY, IT GAVE THE CREW A CHANCE TO GO INTO THE TERMINAL, STRETCH OUR LEGS AND WALK AROUND. IN ESSENCE NO ONE WAS IN A HURRY. CHKLIST WERE READ (ITEMS CHKED) AND THE FUEL LOAD WAS AGREED TO BY BOTH PLTS. THERE MAY HAVE BEEN SOME 'SEE WHAT YOU WANT TO SEE' AND 'EXPENTANCY FACTOR' INVOLVED. I WALKED AROUND THE AIRPLANE BEFORE WE DEPARTED. BEFORE WE READ THE CHKLIST, THE FO NOTED HE HAD ADJUSTED THE FUEL LOAD TO 3800 LBS ON THE LOAD CTL FORM BECAUSE 3700 LBS HAD BEEN WRITTEN IN AND WE WERE OVER SVCED BY APPROX 100 LBS. AT THIS POINT WE READ THE CHKLIST, AGREED ON 3800 LBS WITH A MINIMUM FUEL REQUIREMENT OF 3572 LBS AND A RECOMMMENDED FUEL OF 3617 LBS. AT THIS POINT I WAS PROBABLY PREDISPOSED TO SEEING 3800 LBS. WHAT WE REALLY HAD WAS 2800 LBS AND CHANGE, THAT WE HAD FLOWN IN WITH. TO THE COMPANY'S CREDIT OUR RELEASE AND ESTIMATED FUEL BURNS HAVE BEEN IMPROVED GREATLY OVER THE LAST COUPLE OF YRS. INCLUDED WITH THE RELEASE IS A DETAILED PRINT-OUT CONTAINING THE MAJORITY OF ENRTE FIXES, ETE'S, MILEAGE'S, TAS, GS, TEMPS, FUEL USED AND FUEL REMAINING. I BELIEVED SO MUCH THAT I HAD 3800 LBS WHEN I STARTED THAT AT THE FIRST FEW CHK POINTS I WAS STILL MISINTERPOLATING THE GAUGES AND BELIEVED THEY AGREED WITH THE FUEL BREAKDOWN. IT WASN'T UNTIL WE REACHED MZZ THAT I FOUND THE MISTAKE. THE GAUGES WERE VERY CLOSE TO THE 'LABELED' 1000 LBS MARK ON EACH GAUGE. NO INTERPOLATION REQUIRED. I IMMEDIATELY KNEW WHAT HAPPENED. THE TRUCK NEVER SHOWED. UNLIKE THE LAST COMPANY I WORKED FOR, NO ONE SEEMS TO BE AUDITING THE FUEL PUT ON BOARD AT EACH FUELING WITH WHAT SHOULD HAVE BEEN PUT ON BOARD, BASED ON THE PREVIOUS FLTS REMAINING FUEL. DISCUSSING THIS WITH MY PEERS, THEY RELATED SIMILAR OCCURRENCES -- SOME RPTED, SOME NOT -- IN ALMOST ALL BUT THE MOST SEVERE CASES WHERE THE AIRPLANE HAD TO IMMEDIATELY RETURN TO THE DEP ARPT, THE PROB WAS NOT DISCOVERED UNTIL REACHING THE DEST, WHERE THE CREW FILLS IN THE AIRPLANE LOGS, WHICH REQUIRE FLT TIME AND FUEL USED TO BE ENTERED. I BELIEVE THE LOG HELPED ME IDENT THE MISTAKE MUCH EARLIER THAN IF I HADN'T BEEN USING IT. THE PROB IS MORE PREVALENT THAN I EVER IMAGINED -- TALKING TO ALL THE PLTS WHO HAVE EITHER DONE IT OR ALMOST DID IT. IN THE BACK OF MY MIND, I KEEP HEARING, 'WHAT IF I NEEDED THAT FUEL?' CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID IT WAS THE CREW'S IDEA THE ACFT WAS ALREADY FUELED AND THEY MISREAD THE FUEL QUANTITY INDICATORS. THE RPTR SAID THE COMPANY DOES NOT ISSUE FUEL SLIPS FILLED OUT BY THE FUELER WITH THE POUNDS AND GALS ADDED FROM THE TRUCK METER.
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.