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|
Attributes | |
ACN | 422741 |
Time | |
Date | 199812 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : hnl |
State Reference | HI |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zzz |
Operator | common carrier : air carrier |
Make Model Name | B747-100 |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 40 flight time total : 12900 flight time type : 82 |
ASRS Report | 422741 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 80 flight time total : 10000 flight time type : 2500 |
ASRS Report | 422742 |
Events | |
Anomaly | non adherence : published procedure non adherence : far other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
On dec/fri/98, flight left honolulu for osaka without complying with a new center tank fuel loading requirement. Lack of awareness, incorrect assumptions and miscom all contributed to the noncompliance. Neither the dispatcher nor the fueler were aware of the new requirement, and the airplane was not fueled as per the new procedure. (The dispatcher was new to the airplane.) we, as the flight crew, were aware there was to be a new procedure for fueling the center tank and using the center tank pumps. We had received a notice that said the affected aircraft would be placarded. A second notice was included at the end of the paperwork for our flight that seemed to announce implementation of the new procedure. It was similar to the first notice and it was natural to skim over it. This is where we missed the facts that all B747's were affected, the program was to start immediately and that placarding would take place over time. We were all reserve pilots called out on short notice and may have rushed ourselves slightly, too. However, the second notice was fairly easy to miss since it was about the same subject as the first. It was later in the flight that we realized we had left without being in compliance. We all thought it was odd that placarding was not done simultaneously with implementation, since that would have set off our alarms and made it much more difficult to depart without adhering to the new procedure. Supplemental information from acn 422742: due to in-service inspections which revealed some premature damage to center wing override/jettison pumps the FAA issued an airworthiness directive. This directive was intended to prevent pump operation with little or no fuel in the center tank. This flight was dispatched with normal fuel load prior to the airworthiness directive. The required 17000 pounds in the center tank was not reflected on the release therefore not boarded by the fuelers and not detected by the crew. The flight was flown and arrived with all system and procedures normal except for above mentioned fuel loading. Supplemental information from acn 422740: company directives had gone into affect 4 days prior to this flight that we should have 17000 pounds fuel in the center tank. We were dispatched and had 10000 pounds in the tank. We burned per normal until empty. Directive required fuel to remain in center tank to keep pumps covered.
Original NASA ASRS Text
Title: A B747-200 FLC TAKES AN ACFT WITHOUT THE CTR TANK BEING FUELED CORRECTLY. A NON COMPLIANCE WITH AIRWORTHINESS DIRECTIVE.
Narrative: ON DEC/FRI/98, FLT LEFT HONOLULU FOR OSAKA WITHOUT COMPLYING WITH A NEW CTR TANK FUEL LOADING REQUIREMENT. LACK OF AWARENESS, INCORRECT ASSUMPTIONS AND MISCOM ALL CONTRIBUTED TO THE NONCOMPLIANCE. NEITHER THE DISPATCHER NOR THE FUELER WERE AWARE OF THE NEW REQUIREMENT, AND THE AIRPLANE WAS NOT FUELED AS PER THE NEW PROC. (THE DISPATCHER WAS NEW TO THE AIRPLANE.) WE, AS THE FLC, WERE AWARE THERE WAS TO BE A NEW PROC FOR FUELING THE CTR TANK AND USING THE CTR TANK PUMPS. WE HAD RECEIVED A NOTICE THAT SAID THE AFFECTED ACFT WOULD BE PLACARDED. A SECOND NOTICE WAS INCLUDED AT THE END OF THE PAPERWORK FOR OUR FLT THAT SEEMED TO ANNOUNCE IMPLEMENTATION OF THE NEW PROC. IT WAS SIMILAR TO THE FIRST NOTICE AND IT WAS NATURAL TO SKIM OVER IT. THIS IS WHERE WE MISSED THE FACTS THAT ALL B747'S WERE AFFECTED, THE PROGRAM WAS TO START IMMEDIATELY AND THAT PLACARDING WOULD TAKE PLACE OVER TIME. WE WERE ALL RESERVE PLTS CALLED OUT ON SHORT NOTICE AND MAY HAVE RUSHED OURSELVES SLIGHTLY, TOO. HOWEVER, THE SECOND NOTICE WAS FAIRLY EASY TO MISS SINCE IT WAS ABOUT THE SAME SUBJECT AS THE FIRST. IT WAS LATER IN THE FLT THAT WE REALIZED WE HAD LEFT WITHOUT BEING IN COMPLIANCE. WE ALL THOUGHT IT WAS ODD THAT PLACARDING WAS NOT DONE SIMULTANEOUSLY WITH IMPLEMENTATION, SINCE THAT WOULD HAVE SET OFF OUR ALARMS AND MADE IT MUCH MORE DIFFICULT TO DEPART WITHOUT ADHERING TO THE NEW PROC. SUPPLEMENTAL INFO FROM ACN 422742: DUE TO IN-SVC INSPECTIONS WHICH REVEALED SOME PREMATURE DAMAGE TO CTR WING OVERRIDE/JETTISON PUMPS THE FAA ISSUED AN AIRWORTHINESS DIRECTIVE. THIS DIRECTIVE WAS INTENDED TO PREVENT PUMP OP WITH LITTLE OR NO FUEL IN THE CTR TANK. THIS FLT WAS DISPATCHED WITH NORMAL FUEL LOAD PRIOR TO THE AIRWORTHINESS DIRECTIVE. THE REQUIRED 17000 LBS IN THE CTR TANK WAS NOT REFLECTED ON THE RELEASE THEREFORE NOT BOARDED BY THE FUELERS AND NOT DETECTED BY THE CREW. THE FLT WAS FLOWN AND ARRIVED WITH ALL SYS AND PROCS NORMAL EXCEPT FOR ABOVE MENTIONED FUEL LOADING. SUPPLEMENTAL INFO FROM ACN 422740: COMPANY DIRECTIVES HAD GONE INTO AFFECT 4 DAYS PRIOR TO THIS FLT THAT WE SHOULD HAVE 17000 LBS FUEL IN THE CTR TANK. WE WERE DISPATCHED AND HAD 10000 LBS IN THE TANK. WE BURNED PER NORMAL UNTIL EMPTY. DIRECTIVE REQUIRED FUEL TO REMAIN IN CTR TANK TO KEEP PUMPS COVERED.
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.