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Attributes | |
ACN | 441904 |
Time | |
Date | 199907 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 1000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : takeoff |
Route In Use | departure sid : gapp 3 zzz |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 12000 flight time type : 1300 |
ASRS Report | 441904 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : non compliance with mel maintenance problem : improper documentation maintenance problem : improper maintenance |
Independent Detector | aircraft equipment other aircraft equipment : stab trim warning |
Resolutory Action | flight crew : returned to intended or assigned course none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : manuals performance deficiency : repair performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Maintenance Human Performance Chart Or Publication |
Primary Problem | Maintenance Human Performance |
Situations | |
Publication | MINIMUM EQUIPMENT LIST |
Narrative:
The flight in question is air carrier flight xyz, operated on jun/xa/99. The routing was ZZZ to tokyo, narita. Crew consisted of a captain, first officer and relief first officer. While preparing for the flight, there were a number of deferred maintenance items with the most important being the #2 main fuel tank indicating system inoperative. With the #2 main tank system inoperative, we were not able to doublechk the aircraft center of gravity versus the computed weight and balance. We departed ZZZ with no fuel in the tail tank when the computerized weight and balance showed fuel in the tail tank. Because of this, we departed with an incorrect stabilizer setting. The center of gravity was further forward than anticipated and subsequently led to a nose heavy aircraft on takeoff. There were no control problems but upon activation of the autoplt after takeoff, we received a stabilizer out of trim warning. I missed the tail fuel requirement, both first officer's missed the tail fuel requirement and maintenance missed the tail fuel requirement. In the future, I feel the MEL should not allow any fuel tank indicating system to be inoperative if tail fuel is required. Callback conversation with reporter revealed the following information: the reporter stated the #2 main tank fuel quantity indicating system was inoperative and deferred. The reporter said with the #2 main tank indication inoperative the tail tank fuel cannot be used for center of gravity management. The reporter said the onboard computer showed fuel in the tail tank and calculated the center of gravity forward. The reporter said no fuel was loaded in the tail tank. The reporter stated the MD11 MEL requirements for operating the aircraft with the #2 main tank quantity system inoperative consists of 8-10 conflicting and complex restrs which can be and are confusing. The reporter said getting the correct dipstick readings was a problem as maintenance did not have the proper charts for the stick readings. The reporter said when advised of this situation the company said the stick readings were not available but were similar to the DC10-30. The reporter stated the center tank was fueled using the gallons added from the truck. The reporter stated no main fuel system should be allowed to be deferred.
Original NASA ASRS Text
Title: AN MD11 AT 1000 FT ON TKOF CLB EXPERIENCES A NOSE HVY ACFT DUE TO THE INCORRECT CTR OF GRAVITY SETTING CAUSED BY THE #2 MAIN TANK FUEL QUANTITY INDICATOR DEFERRED AS INOP.
Narrative: THE FLT IN QUESTION IS ACR FLT XYZ, OPERATED ON JUN/XA/99. THE ROUTING WAS ZZZ TO TOKYO, NARITA. CREW CONSISTED OF A CAPT, FO AND RELIEF FO. WHILE PREPARING FOR THE FLT, THERE WERE A NUMBER OF DEFERRED MAINT ITEMS WITH THE MOST IMPORTANT BEING THE #2 MAIN FUEL TANK INDICATING SYS INOP. WITH THE #2 MAIN TANK SYS INOP, WE WERE NOT ABLE TO DOUBLECHK THE ACFT CTR OF GRAVITY VERSUS THE COMPUTED WT AND BAL. WE DEPARTED ZZZ WITH NO FUEL IN THE TAIL TANK WHEN THE COMPUTERIZED WT AND BAL SHOWED FUEL IN THE TAIL TANK. BECAUSE OF THIS, WE DEPARTED WITH AN INCORRECT STABILIZER SETTING. THE CTR OF GRAVITY WAS FURTHER FORWARD THAN ANTICIPATED AND SUBSEQUENTLY LED TO A NOSE HVY ACFT ON TKOF. THERE WERE NO CTL PROBS BUT UPON ACTIVATION OF THE AUTOPLT AFTER TKOF, WE RECEIVED A STABILIZER OUT OF TRIM WARNING. I MISSED THE TAIL FUEL REQUIREMENT, BOTH FO'S MISSED THE TAIL FUEL REQUIREMENT AND MAINT MISSED THE TAIL FUEL REQUIREMENT. IN THE FUTURE, I FEEL THE MEL SHOULD NOT ALLOW ANY FUEL TANK INDICATING SYS TO BE INOP IF TAIL FUEL IS REQUIRED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE #2 MAIN TANK FUEL QUANTITY INDICATING SYS WAS INOP AND DEFERRED. THE RPTR SAID WITH THE #2 MAIN TANK INDICATION INOP THE TAIL TANK FUEL CANNOT BE USED FOR CTR OF GRAVITY MGMNT. THE RPTR SAID THE ONBOARD COMPUTER SHOWED FUEL IN THE TAIL TANK AND CALCULATED THE CTR OF GRAVITY FORWARD. THE RPTR SAID NO FUEL WAS LOADED IN THE TAIL TANK. THE RPTR STATED THE MD11 MEL REQUIREMENTS FOR OPERATING THE ACFT WITH THE #2 MAIN TANK QUANTITY SYS INOP CONSISTS OF 8-10 CONFLICTING AND COMPLEX RESTRS WHICH CAN BE AND ARE CONFUSING. THE RPTR SAID GETTING THE CORRECT DIPSTICK READINGS WAS A PROB AS MAINT DID NOT HAVE THE PROPER CHARTS FOR THE STICK READINGS. THE RPTR SAID WHEN ADVISED OF THIS SIT THE COMPANY SAID THE STICK READINGS WERE NOT AVAILABLE BUT WERE SIMILAR TO THE DC10-30. THE RPTR STATED THE CTR TANK WAS FUELED USING THE GALLONS ADDED FROM THE TRUCK. THE RPTR STATED NO MAIN FUEL SYS SHOULD BE ALLOWED TO BE DEFERRED.
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.