37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 397910 |
Time | |
Date | 199803 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : cdc |
State Reference | UT |
Altitude | msl bound lower : 33000 msl bound upper : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Route In Use | enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 12000 flight time type : 6000 |
ASRS Report | 397910 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the captain on a B727 which departed lax for den with 46000 pounds of fuel. We landed with 24000 pounds, as planned, but with one major problem -- the individual fuel tank quantities read #1 -- 11600 pounds, #2 -- 800 pounds, #3 -- 11600 pounds. The xfeed valves had never been closed. In the vicinity of zion nat'l park, the so announced 'xfeeding complete' and turned on the boost pumps in tanks #1 and #3, which I observed. At the time, I had been pointing out the geographical sights to the passenger over the PA, as well as passing on to my crew numerous details of the area. As the so later recalled he had delayed closing the xfeed valves because #2 was just slightly high yet, and he was going to 'perfectly' balance all 3 tanks. He was then distracted by my commentary, and forgot to complete the process. This condition was not noticed during subsequent fuel checks because the so had a unique 'shortcut' for totaling the fuel gauge readings (which he has since abandoned) and I was only looking back at the totalizer for a quick check of the fuel. This imbalance was not noticed until after block in. The flight landed without incident, and incredibly to me, the out of limit center of gravity problem that we are led to expect was not noticeable to me as I hand flew the aircraft through descent and landing. (The cabin was full.) the so has enumerated his remedies separately, but from the perspective of the left seat (captain) I offer 3 points to heed: 1) treat the completion of fuel xfeeding with the same seriousness we give to altitude leveloffs. Cut out any distractions at that time. 2) as the captain, notice more than the boost pumps on, with the lights out. Look at the xfeed valve position. 3) don't let down your guard because the pilot with whom you're flying is above average experience/talent or you've flown together many times.
Original NASA ASRS Text
Title: THE FE ON A B727 FORGOT TO TURN OFF THE XFEED VALVES AFTER XFERRING FUEL DURING CRUISE CAUSING A FUEL IMBALANCE. THE MISTAKE WAS DISCOVERED DURING POSTFLT WHEN THE CAPT NOTICED THE FUEL IMBALANCE AFTER CHKING THE QUANTITY IN EACH TANK. THE CAPT DID NOT NOTICE ANY ACFT TRIM DIFFICULTY WHEN MANUALLY FLYING THE ACFT DURING APCH AND LNDG.
Narrative: I WAS THE CAPT ON A B727 WHICH DEPARTED LAX FOR DEN WITH 46000 LBS OF FUEL. WE LANDED WITH 24000 LBS, AS PLANNED, BUT WITH ONE MAJOR PROB -- THE INDIVIDUAL FUEL TANK QUANTITIES READ #1 -- 11600 LBS, #2 -- 800 LBS, #3 -- 11600 LBS. THE XFEED VALVES HAD NEVER BEEN CLOSED. IN THE VICINITY OF ZION NAT'L PARK, THE SO ANNOUNCED 'XFEEDING COMPLETE' AND TURNED ON THE BOOST PUMPS IN TANKS #1 AND #3, WHICH I OBSERVED. AT THE TIME, I HAD BEEN POINTING OUT THE GEOGRAPHICAL SIGHTS TO THE PAX OVER THE PA, AS WELL AS PASSING ON TO MY CREW NUMEROUS DETAILS OF THE AREA. AS THE SO LATER RECALLED HE HAD DELAYED CLOSING THE XFEED VALVES BECAUSE #2 WAS JUST SLIGHTLY HIGH YET, AND HE WAS GOING TO 'PERFECTLY' BAL ALL 3 TANKS. HE WAS THEN DISTRACTED BY MY COMMENTARY, AND FORGOT TO COMPLETE THE PROCESS. THIS CONDITION WAS NOT NOTICED DURING SUBSEQUENT FUEL CHKS BECAUSE THE SO HAD A UNIQUE 'SHORTCUT' FOR TOTALING THE FUEL GAUGE READINGS (WHICH HE HAS SINCE ABANDONED) AND I WAS ONLY LOOKING BACK AT THE TOTALIZER FOR A QUICK CHK OF THE FUEL. THIS IMBALANCE WAS NOT NOTICED UNTIL AFTER BLOCK IN. THE FLT LANDED WITHOUT INCIDENT, AND INCREDIBLY TO ME, THE OUT OF LIMIT CTR OF GRAVITY PROB THAT WE ARE LED TO EXPECT WAS NOT NOTICEABLE TO ME AS I HAND FLEW THE ACFT THROUGH DSCNT AND LNDG. (THE CABIN WAS FULL.) THE SO HAS ENUMERATED HIS REMEDIES SEPARATELY, BUT FROM THE PERSPECTIVE OF THE L SEAT (CAPT) I OFFER 3 POINTS TO HEED: 1) TREAT THE COMPLETION OF FUEL XFEEDING WITH THE SAME SERIOUSNESS WE GIVE TO ALT LEVELOFFS. CUT OUT ANY DISTRACTIONS AT THAT TIME. 2) AS THE CAPT, NOTICE MORE THAN THE BOOST PUMPS ON, WITH THE LIGHTS OUT. LOOK AT THE XFEED VALVE POS. 3) DON'T LET DOWN YOUR GUARD BECAUSE THE PLT WITH WHOM YOU'RE FLYING IS ABOVE AVERAGE EXPERIENCE/TALENT OR YOU'VE FLOWN TOGETHER MANY TIMES.
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.