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Attributes | |
ACN | 433461 |
Time | |
Date | 199904 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : anc.airport |
State Reference | AK |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Twin Otter DHC-6 |
Operating Under FAR Part | Part 135 |
Flight Phase | ground : taxi |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 80 flight time total : 350 flight time type : 50 |
ASRS Report | 433461 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time type : 1000 |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to alternate |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We had a 1 1/2 hour break and decided to go back to the FBO to eat dinner. The captain left a fuel request for our next flight to homer, ak, for 1600 pounds of fuel to the ramp agents before we left. When we returned, I went into the terminal and completed the weight and balance. I returned to the aircraft and gave the safety briefing to the passenger. After completing the briefing, the captain asked if it was 'clear right' and I responded 'clear right' as he began starter rotation on the right engine. After starting the engines, we performed the 'after start' and 'before takeoff' checklists as we taxied out to the runway. It was my leg, so I took the controls as we taxied onto the runway. We departed the airport and used a r-hand downwind departure as instructed by tower. About 5 mins later, the captain called in our out/off times and fuel on board to discover that we only had about 700-720 pounds of fuel on board at that instant in time. Our minimum dispatch fuel to homer was 950 pounds. Anchorage was dealing with an emergency due to a B737 that was having gear problems, so we decided to divert to kenai for fuel. The minimum dispatch fuel to kenai was 750 pounds that day, which we calculated we had prior to takeoff. We notified the dispatcher of our intentions and were rereleased to homer via kenai. We landed in kenai and received our new release and fuel, informed the passenger of the situation, and continued to homer. Once we returned to anchorage, we were relieved of duty and the next day we were both given a week off without pay. The factors that contributed to this situation are the fact that we diverted from SOP's. I was previously instructed by the PIC that he would complete the 'before start' checklist to himself while I compute the weight and balance or brief the passenger in order to expedite activity. The before start checklist is a crew checklist and should be completed by the captain and first officer simultaneously. The second factor, which may have contributed to the problem occurred during completing the weight and balance. I had been using the fuel indicated on the release and requested by the captain, as do most first officer's at this company. Since we are often weight limited and we use actual passenger weights, the first officer usually stays inside with the gate agent to let him/her know how many passenger we can take, based on the fuel indicated by the captain per our release. We make the assumption that the ramp will put on the proper amount of fuel. This problem could have been prevented by following SOP's. Once the problem was discovered, it is my belief that we performed the proper corrective actions to resolve our mistake. It was out intent not to complicate matters or jeopardize safety, so the captain made the decision to divert to kenai. The stop in kenai for fuel delayed our arrival in homer by 12 mins. I feel the time lost is insignificant to the added safety that was gained by stopping for fuel. Some human performance considerations include the fact that both of us had very little experience for the situation we were in. The captain only had about 100 hours of PIC time in the aircraft and approximately 1000 hours of sic time in the aircraft. I only had about 50 hours of sic time in the aircraft. The other human factor that contributed to this problem was repetition. We had been flying together the last 3-4 days doing the exact same lines and had built the routine that the captain would perform the 'before start' checklist which has a call for 'fuel quantity/system -- checked/normal -- (captain's response).' to remedy further sits, I will always question the captain's authority/authorized to deviate from SOP. I am also working with our director of operations on promoting the use and importance of checklists. Finally, it is my goal to review the weight and balance procedures and try to establish a procedure that will allow efficiency and accuracy.
Original NASA ASRS Text
Title: A DHC6 FLC DEPARTED WITH LESS THAN DISPATCH FUEL AND HAD TO DIVERT TO AN ENRTE ALTERNATE.
Narrative: WE HAD A 1 1/2 HR BREAK AND DECIDED TO GO BACK TO THE FBO TO EAT DINNER. THE CAPT LEFT A FUEL REQUEST FOR OUR NEXT FLT TO HOMER, AK, FOR 1600 LBS OF FUEL TO THE RAMP AGENTS BEFORE WE LEFT. WHEN WE RETURNED, I WENT INTO THE TERMINAL AND COMPLETED THE WT AND BAL. I RETURNED TO THE ACFT AND GAVE THE SAFETY BRIEFING TO THE PAX. AFTER COMPLETING THE BRIEFING, THE CAPT ASKED IF IT WAS 'CLR R' AND I RESPONDED 'CLR R' AS HE BEGAN STARTER ROTATION ON THE R ENG. AFTER STARTING THE ENGS, WE PERFORMED THE 'AFTER START' AND 'BEFORE TKOF' CHKLISTS AS WE TAXIED OUT TO THE RWY. IT WAS MY LEG, SO I TOOK THE CTLS AS WE TAXIED ONTO THE RWY. WE DEPARTED THE ARPT AND USED A R-HAND DOWNWIND DEP AS INSTRUCTED BY TWR. ABOUT 5 MINS LATER, THE CAPT CALLED IN OUR OUT/OFF TIMES AND FUEL ON BOARD TO DISCOVER THAT WE ONLY HAD ABOUT 700-720 LBS OF FUEL ON BOARD AT THAT INSTANT IN TIME. OUR MINIMUM DISPATCH FUEL TO HOMER WAS 950 LBS. ANCHORAGE WAS DEALING WITH AN EMER DUE TO A B737 THAT WAS HAVING GEAR PROBS, SO WE DECIDED TO DIVERT TO KENAI FOR FUEL. THE MINIMUM DISPATCH FUEL TO KENAI WAS 750 LBS THAT DAY, WHICH WE CALCULATED WE HAD PRIOR TO TKOF. WE NOTIFIED THE DISPATCHER OF OUR INTENTIONS AND WERE RERELEASED TO HOMER VIA KENAI. WE LANDED IN KENAI AND RECEIVED OUR NEW RELEASE AND FUEL, INFORMED THE PAX OF THE SIT, AND CONTINUED TO HOMER. ONCE WE RETURNED TO ANCHORAGE, WE WERE RELIEVED OF DUTY AND THE NEXT DAY WE WERE BOTH GIVEN A WK OFF WITHOUT PAY. THE FACTORS THAT CONTRIBUTED TO THIS SIT ARE THE FACT THAT WE DIVERTED FROM SOP'S. I WAS PREVIOUSLY INSTRUCTED BY THE PIC THAT HE WOULD COMPLETE THE 'BEFORE START' CHKLIST TO HIMSELF WHILE I COMPUTE THE WT AND BAL OR BRIEF THE PAX IN ORDER TO EXPEDITE ACTIVITY. THE BEFORE START CHKLIST IS A CREW CHKLIST AND SHOULD BE COMPLETED BY THE CAPT AND FO SIMULTANEOUSLY. THE SECOND FACTOR, WHICH MAY HAVE CONTRIBUTED TO THE PROB OCCURRED DURING COMPLETING THE WT AND BAL. I HAD BEEN USING THE FUEL INDICATED ON THE RELEASE AND REQUESTED BY THE CAPT, AS DO MOST FO'S AT THIS COMPANY. SINCE WE ARE OFTEN WT LIMITED AND WE USE ACTUAL PAX WTS, THE FO USUALLY STAYS INSIDE WITH THE GATE AGENT TO LET HIM/HER KNOW HOW MANY PAX WE CAN TAKE, BASED ON THE FUEL INDICATED BY THE CAPT PER OUR RELEASE. WE MAKE THE ASSUMPTION THAT THE RAMP WILL PUT ON THE PROPER AMOUNT OF FUEL. THIS PROB COULD HAVE BEEN PREVENTED BY FOLLOWING SOP'S. ONCE THE PROB WAS DISCOVERED, IT IS MY BELIEF THAT WE PERFORMED THE PROPER CORRECTIVE ACTIONS TO RESOLVE OUR MISTAKE. IT WAS OUT INTENT NOT TO COMPLICATE MATTERS OR JEOPARDIZE SAFETY, SO THE CAPT MADE THE DECISION TO DIVERT TO KENAI. THE STOP IN KENAI FOR FUEL DELAYED OUR ARR IN HOMER BY 12 MINS. I FEEL THE TIME LOST IS INSIGNIFICANT TO THE ADDED SAFETY THAT WAS GAINED BY STOPPING FOR FUEL. SOME HUMAN PERFORMANCE CONSIDERATIONS INCLUDE THE FACT THAT BOTH OF US HAD VERY LITTLE EXPERIENCE FOR THE SIT WE WERE IN. THE CAPT ONLY HAD ABOUT 100 HRS OF PIC TIME IN THE ACFT AND APPROX 1000 HRS OF SIC TIME IN THE ACFT. I ONLY HAD ABOUT 50 HRS OF SIC TIME IN THE ACFT. THE OTHER HUMAN FACTOR THAT CONTRIBUTED TO THIS PROB WAS REPETITION. WE HAD BEEN FLYING TOGETHER THE LAST 3-4 DAYS DOING THE EXACT SAME LINES AND HAD BUILT THE ROUTINE THAT THE CAPT WOULD PERFORM THE 'BEFORE START' CHKLIST WHICH HAS A CALL FOR 'FUEL QUANTITY/SYS -- CHKED/NORMAL -- (CAPT'S RESPONSE).' TO REMEDY FURTHER SITS, I WILL ALWAYS QUESTION THE CAPT'S AUTH TO DEVIATE FROM SOP. I AM ALSO WORKING WITH OUR DIRECTOR OF OPS ON PROMOTING THE USE AND IMPORTANCE OF CHKLISTS. FINALLY, IT IS MY GOAL TO REVIEW THE WT AND BAL PROCS AND TRY TO ESTABLISH A PROC THAT WILL ALLOW EFFICIENCY AND ACCURACY.
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.