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Attributes | |
ACN | 414690 |
Time | |
Date | 199809 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dfw |
State Reference | TX |
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 | DC-8 70 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : parked other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 50 flight time total : 10000 flight time type : 3700 |
ASRS Report | 414690 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 130 flight time total : 7000 flight time type : 4001 |
ASRS Report | 415198 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : rejected takeoff |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During the takeoff at V1, the airplane began to yaw and dip to the left. Takeoff was rejected and runway cleared easily at about the 1/2 way point. Reject speed about 120 KIAS at 212000 pounds gross takeoff weight. While taxiing, discovered that the #1 main fuel tank was virtually empty thus starving the #1 engine for fuel. Apparently the engine had flamed out during takeoff, then relit during the rejected takeoff. Further investigation found a fuel valve open which had allowed the main tank to pump itself empty into another tank. This was a crew related fuel mismgmnt problem. Both the captain and so missed seeing: low tank quantity, fuel xfer light and low pump pressure light, low tank quantity warning light, and fuel fill valve switch in wrong position. Note: the first officer, due to seating geometry, cannot see the fuel panel without twisting around in his seat. Factors involved -- note: we fully accept responsibility for the fact that the crew is ultimately responsible for condition of the aircraft. Nonetheless: fuel valve switch was most likely left open by a refueler. The so had flown only twice in nearly 2 months -- proficiency will suffer if skills aren't exercised. Pretkof routine was short. The takeoff runway was at the ramp exit. While the checklists were not 'rushed' there was no idle time prior to takeoff. Fatigue -- this occurred during the 10TH hour of a 12 hour duty assignment. After the rejected takeoff, we consulted the brake energy chart, which while calling for some brake cooling, did not prohibit setting the parking brake (higher energy levels would have). After correcting our fuel problem and running checklists, we attempted to taxi and found airplane frozen in position. Later, maintenance found several brake discs welded together, most likely due to heat generated by rejected takeoff. While talking to maintenance, found that their manuals called for 2 hours of ground cooling while the pilot's manual permits 12 mins of flight cooling. Supplemental information from acn 415198: plus outside air temperature was 96 degrees F. Supplemental information from acn 415196: V1 for the takeoff =119 KTS. The aircraft weighed 212300 pounds. (Considered to be a light-weight takeoff for the DC8-73.) at V1 during the takeoff roll, the aircraft yawed to the left. The captain aborted the takeoff immediately, at a speed estimated to be 121-123 KTS. The runway was cleared with all engines running. Brake cooling charts were reviewed, and the parking brake was set. Found: 1) #1 alternate tank fill valve switch in open position. 2) #1 feed pump light illuminated (indicating low pump output). 3) #1 main tank qty low light illuminated. The apparent cause for the loss of power from the #1 engine was fuel starvation, caused by the unintentional pumping of 3000 pounds of fuel from the #1 main tank to the #1 alternate tank. This resulted from having the #1 electric boost pump on (normal position), and having the #1 alternate refill switch open (abnormal position). The #1 alternate tank refill switch was left in the wrong position by the fueler. Procedures call for leaving only the #3 main refill valve open, after fueling, to allow for fuel expansion. Also, the through-flight checklist for this aircraft does not include the checking of refill valve switches. The taxi out was very short due to the close proximity of the runway. The situation was further exacerbated by the captain's decision to use nonstandard procedures in order to continue to run air conditioning packs while starting the outboard engines during the taxi. This resulted in a very high workload for the engineer (me), and a subsequent breakdown of the normal instrument scan. Additionally, while taking the runway, I had to leave my duty station to open the main cargo conditioned air shutoff valve, which the captain had closed to provide more cooling air to the cockpit (also a nonstandard procedure). As I resecured my shoulder harness, the aircraft was in position on the runway with the captain and first officer ready to depart. As the takeoff roll began, the sun happened to be shining directly on the flight engineer panel, possibly masking the feed pump light which may have been illuminated at this point, but could have only illuminated when the fuel flows increased. Company procedures call for the engineer to primarily monitor the engine gauges on the front panel during the takeoff roll. While most of the DC8-73 aircraft in our company's fleet have been retrofitted with all digital fuel gauges, this particular aircraft contained older style gauges, with quantity displayed in an 'odometer' style. (There is no pointer to display a relative fuel quantity.) I had not operated with this style of gauge since simulator training. The gauge in question displayed an amount less than zero for an empty tank (09950), while the new system would have just displayed zeros (00000) for an empty tank. The main tank refill valve switches on this (all the fleet) aircraft are rotary type knobs with markings which make it easy to see their position. Meanwhile, the alternate tank refill valve switches (for unknown reasons) are regular, locking switches, which, it is found, must be physically touched to confirm their position. The flight engineer received 2.0 hours ground school on the fuel system and 2.0 hours simulator training on the fuel system. The check airman in charge noted on the additional training paperwork that the flight engineer '...displayed good knowledge of the fuel system and procedures....'
Original NASA ASRS Text
Title: A DC8-73 ABORTS ITS TKOF WHEN THE #1 ENG FAILS DUE TO FUEL STARVATION. WHEN THE BRAKES ARE PARKED FOR AN ACFT STATUS REVIEW THE CREW LATER DISCOVERS THAT THE BRAKES ARE FUSED, THE ACFT IS UNABLE TO MOVE. THE FUEL EXHAUSTION WAS CREATED BY THE #1 ALTERNATE TANK FILL VALVE IN OPEN POS, ALLOWING FUEL TO XFER FROM #1 TANK TO THE #1 ALTERNATE FUEL TANK.
Narrative: DURING THE TKOF AT V1, THE AIRPLANE BEGAN TO YAW AND DIP TO THE L. TKOF WAS REJECTED AND RWY CLRED EASILY AT ABOUT THE 1/2 WAY POINT. REJECT SPD ABOUT 120 KIAS AT 212000 LBS GROSS TKOF WT. WHILE TAXIING, DISCOVERED THAT THE #1 MAIN FUEL TANK WAS VIRTUALLY EMPTY THUS STARVING THE #1 ENG FOR FUEL. APPARENTLY THE ENG HAD FLAMED OUT DURING TKOF, THEN RELIT DURING THE REJECTED TKOF. FURTHER INVESTIGATION FOUND A FUEL VALVE OPEN WHICH HAD ALLOWED THE MAIN TANK TO PUMP ITSELF EMPTY INTO ANOTHER TANK. THIS WAS A CREW RELATED FUEL MISMGMNT PROB. BOTH THE CAPT AND SO MISSED SEEING: LOW TANK QUANTITY, FUEL XFER LIGHT AND LOW PUMP PRESSURE LIGHT, LOW TANK QUANTITY WARNING LIGHT, AND FUEL FILL VALVE SWITCH IN WRONG POS. NOTE: THE FO, DUE TO SEATING GEOMETRY, CANNOT SEE THE FUEL PANEL WITHOUT TWISTING AROUND IN HIS SEAT. FACTORS INVOLVED -- NOTE: WE FULLY ACCEPT RESPONSIBILITY FOR THE FACT THAT THE CREW IS ULTIMATELY RESPONSIBLE FOR CONDITION OF THE ACFT. NONETHELESS: FUEL VALVE SWITCH WAS MOST LIKELY LEFT OPEN BY A REFUELER. THE SO HAD FLOWN ONLY TWICE IN NEARLY 2 MONTHS -- PROFICIENCY WILL SUFFER IF SKILLS AREN'T EXERCISED. PRETKOF ROUTINE WAS SHORT. THE TKOF RWY WAS AT THE RAMP EXIT. WHILE THE CHKLISTS WERE NOT 'RUSHED' THERE WAS NO IDLE TIME PRIOR TO TKOF. FATIGUE -- THIS OCCURRED DURING THE 10TH HR OF A 12 HR DUTY ASSIGNMENT. AFTER THE REJECTED TKOF, WE CONSULTED THE BRAKE ENERGY CHART, WHICH WHILE CALLING FOR SOME BRAKE COOLING, DID NOT PROHIBIT SETTING THE PARKING BRAKE (HIGHER ENERGY LEVELS WOULD HAVE). AFTER CORRECTING OUR FUEL PROB AND RUNNING CHKLISTS, WE ATTEMPTED TO TAXI AND FOUND AIRPLANE FROZEN IN POS. LATER, MAINT FOUND SEVERAL BRAKE DISCS WELDED TOGETHER, MOST LIKELY DUE TO HEAT GENERATED BY REJECTED TKOF. WHILE TALKING TO MAINT, FOUND THAT THEIR MANUALS CALLED FOR 2 HRS OF GND COOLING WHILE THE PLT'S MANUAL PERMITS 12 MINS OF FLT COOLING. SUPPLEMENTAL INFO FROM ACN 415198: PLUS OUTSIDE AIR TEMP WAS 96 DEGS F. SUPPLEMENTAL INFO FROM ACN 415196: V1 FOR THE TKOF =119 KTS. THE ACFT WEIGHED 212300 LBS. (CONSIDERED TO BE A LIGHT-WT TKOF FOR THE DC8-73.) AT V1 DURING THE TKOF ROLL, THE ACFT YAWED TO THE L. THE CAPT ABORTED THE TKOF IMMEDIATELY, AT A SPD ESTIMATED TO BE 121-123 KTS. THE RWY WAS CLRED WITH ALL ENGS RUNNING. BRAKE COOLING CHARTS WERE REVIEWED, AND THE PARKING BRAKE WAS SET. FOUND: 1) #1 ALTERNATE TANK FILL VALVE SWITCH IN OPEN POS. 2) #1 FEED PUMP LIGHT ILLUMINATED (INDICATING LOW PUMP OUTPUT). 3) #1 MAIN TANK QTY LOW LIGHT ILLUMINATED. THE APPARENT CAUSE FOR THE LOSS OF PWR FROM THE #1 ENG WAS FUEL STARVATION, CAUSED BY THE UNINTENTIONAL PUMPING OF 3000 LBS OF FUEL FROM THE #1 MAIN TANK TO THE #1 ALTERNATE TANK. THIS RESULTED FROM HAVING THE #1 ELECTRIC BOOST PUMP ON (NORMAL POS), AND HAVING THE #1 ALTERNATE REFILL SWITCH OPEN (ABNORMAL POS). THE #1 ALTERNATE TANK REFILL SWITCH WAS LEFT IN THE WRONG POS BY THE FUELER. PROCS CALL FOR LEAVING ONLY THE #3 MAIN REFILL VALVE OPEN, AFTER FUELING, TO ALLOW FOR FUEL EXPANSION. ALSO, THE THROUGH-FLT CHKLIST FOR THIS ACFT DOES NOT INCLUDE THE CHKING OF REFILL VALVE SWITCHES. THE TAXI OUT WAS VERY SHORT DUE TO THE CLOSE PROX OF THE RWY. THE SIT WAS FURTHER EXACERBATED BY THE CAPT'S DECISION TO USE NONSTANDARD PROCS IN ORDER TO CONTINUE TO RUN AIR CONDITIONING PACKS WHILE STARTING THE OUTBOARD ENGS DURING THE TAXI. THIS RESULTED IN A VERY HIGH WORKLOAD FOR THE ENGINEER (ME), AND A SUBSEQUENT BREAKDOWN OF THE NORMAL INST SCAN. ADDITIONALLY, WHILE TAKING THE RWY, I HAD TO LEAVE MY DUTY STATION TO OPEN THE MAIN CARGO CONDITIONED AIR SHUTOFF VALVE, WHICH THE CAPT HAD CLOSED TO PROVIDE MORE COOLING AIR TO THE COCKPIT (ALSO A NONSTANDARD PROC). AS I RESECURED MY SHOULDER HARNESS, THE ACFT WAS IN POS ON THE RWY WITH THE CAPT AND FO READY TO DEPART. AS THE TKOF ROLL BEGAN, THE SUN HAPPENED TO BE SHINING DIRECTLY ON THE FE PANEL, POSSIBLY MASKING THE FEED PUMP LIGHT WHICH MAY HAVE BEEN ILLUMINATED AT THIS POINT, BUT COULD HAVE ONLY ILLUMINATED WHEN THE FUEL FLOWS INCREASED. COMPANY PROCS CALL FOR THE ENGINEER TO PRIMARILY MONITOR THE ENG GAUGES ON THE FRONT PANEL DURING THE TKOF ROLL. WHILE MOST OF THE DC8-73 ACFT IN OUR COMPANY'S FLEET HAVE BEEN RETROFITTED WITH ALL DIGITAL FUEL GAUGES, THIS PARTICULAR ACFT CONTAINED OLDER STYLE GAUGES, WITH QUANTITY DISPLAYED IN AN 'ODOMETER' STYLE. (THERE IS NO POINTER TO DISPLAY A RELATIVE FUEL QUANTITY.) I HAD NOT OPERATED WITH THIS STYLE OF GAUGE SINCE SIMULATOR TRAINING. THE GAUGE IN QUESTION DISPLAYED AN AMOUNT LESS THAN ZERO FOR AN EMPTY TANK (09950), WHILE THE NEW SYS WOULD HAVE JUST DISPLAYED ZEROS (00000) FOR AN EMPTY TANK. THE MAIN TANK REFILL VALVE SWITCHES ON THIS (ALL THE FLEET) ACFT ARE ROTARY TYPE KNOBS WITH MARKINGS WHICH MAKE IT EASY TO SEE THEIR POS. MEANWHILE, THE ALTERNATE TANK REFILL VALVE SWITCHES (FOR UNKNOWN REASONS) ARE REGULAR, LOCKING SWITCHES, WHICH, IT IS FOUND, MUST BE PHYSICALLY TOUCHED TO CONFIRM THEIR POS. THE FE RECEIVED 2.0 HRS GND SCHOOL ON THE FUEL SYS AND 2.0 HRS SIMULATOR TRAINING ON THE FUEL SYS. THE CHK AIRMAN IN CHARGE NOTED ON THE ADDITIONAL TRAINING PAPERWORK THAT THE FE '...DISPLAYED GOOD KNOWLEDGE OF THE FUEL SYS AND PROCS....'
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.