37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 450646 |
Time | |
Date | 199910 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : cfi pilot : atp pilot : flight engineer pilot : multi engine |
Experience | flight time last 90 days : 150 flight time total : 3000 flight time type : 150 |
ASRS Report | 450646 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper documentation maintenance problem : improper maintenance maintenance problem : non compliance with mel non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : fueling dipsticks |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : testing performance deficiency : inspection performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Maintenance Human Performance Aircraft |
Primary Problem | Maintenance Human Performance |
Narrative:
Upon arrival at aircraft for a scheduled flight from ZZZ to okc, my first act after entering the cockpit was to review the aircraft logbook. This logbook alerted me to 3 items, one of which was the inoperative status of the #3 fuel gauge. Also in the logbook was an entry made by maintenance detailing how the tank had been fueled with a known quantity of fuel complete with the mechanic's signature and certificate number. Making sure the captain was alerted to these facts, I informed him of the write-ups, and handed him the logbook. I then performed a fuel quantity check to determine if the fuel quantities matched. The calculation indicated that we were approximately 700 gallons short of fuel. After double- and triplechking my calculations, I alerted the captain as to my discovery. He looked at the data and performed some calculations of his own and confirmed that there was a discrepancy. He suggested checking the numbers on the fuel slip to determine if the fueler had performed the correct calculations. They were correct. At this time he directed me to go outside to the fueling panel on the underside of the wing and take a look there. However, my actions outside the aircraft alerted the mechanic, who met me as I walked back towards the cockpit. He asked me what the problem was. I informed him that we were having a problem verifying how much fuel was on the airplane. He stated that he had fueled that tank and it was topped off. I further emphasized the fact that our calculations showed that we were 700 gallons short of fuel. He restated that he was positive the tank was full of fuel. During the ensuring flight, I observed no indications that ever caused me to doubt that our previous conclusions concerning the 700 gallons of fuel were not valid. It was during our refueling procedure that the first indication of a problem arose. No matter how we configured the fuel system, we could not seem to get much fuel out of tank #3. After numerous system checks and a dripstick of tank #3, we determined that the tank had been very nearly empty when we shut the engine down at the gate. At this point, we decided to fill this now verified empty tank from the truck and determine a known quantity in it by checking it against the meter on the truck. We expected a total of approximately 1717 gallons. At this time, both the first officer and myself were observing the fueling operation by the truck. At 1054 gallons the volumetric top off system erroneously closed the fueling valve. The mechanic then checked the dripstick and stated that the tank was not full. He reset the system and fueling was resumed. I continued to observe the fueling operation until the volumetric top off system again stopped fueling. This time, however, the meter indicated 1717 gallons. This matched the known quantity we expected to pump into the tank. The total fuel uplift calculations verified this. We were now satisfied that we had the proper amount of fuel at this time. The remainder of the trip proceeded without incident. Our company policies state that maintenance is responsible for verifying the fuel load in the tank with the inoperative fuel gauge. It appears obvious that they were not thorough in their duties and were fooled by a faulty volumetric top off indication, which stopped fueling to that tank approximately 700 gallons short of full. Proper action by the flight crew could have prevented this incident, however. The fuel quantity check I had performed earlier gave us some indication that there was a problem. Whenever a contradiction such as this occurs, it is the duty of the flight crew to now verify it for themselves. That would have prevented this incident.
Original NASA ASRS Text
Title: A B727-200 WAS DISPATCHED IN NON COMPLIANCE WITH INADEQUATE FUEL BOARDED IN #3 TANK USING INOP INDICATOR PROCS.
Narrative: UPON ARR AT ACFT FOR A SCHEDULED FLT FROM ZZZ TO OKC, MY FIRST ACT AFTER ENTERING THE COCKPIT WAS TO REVIEW THE ACFT LOGBOOK. THIS LOGBOOK ALERTED ME TO 3 ITEMS, ONE OF WHICH WAS THE INOP STATUS OF THE #3 FUEL GAUGE. ALSO IN THE LOGBOOK WAS AN ENTRY MADE BY MAINT DETAILING HOW THE TANK HAD BEEN FUELED WITH A KNOWN QUANTITY OF FUEL COMPLETE WITH THE MECH'S SIGNATURE AND CERTIFICATE NUMBER. MAKING SURE THE CAPT WAS ALERTED TO THESE FACTS, I INFORMED HIM OF THE WRITE-UPS, AND HANDED HIM THE LOGBOOK. I THEN PERFORMED A FUEL QUANTITY CHK TO DETERMINE IF THE FUEL QUANTITIES MATCHED. THE CALCULATION INDICATED THAT WE WERE APPROX 700 GALLONS SHORT OF FUEL. AFTER DOUBLE- AND TRIPLECHKING MY CALCULATIONS, I ALERTED THE CAPT AS TO MY DISCOVERY. HE LOOKED AT THE DATA AND PERFORMED SOME CALCULATIONS OF HIS OWN AND CONFIRMED THAT THERE WAS A DISCREPANCY. HE SUGGESTED CHKING THE NUMBERS ON THE FUEL SLIP TO DETERMINE IF THE FUELER HAD PERFORMED THE CORRECT CALCULATIONS. THEY WERE CORRECT. AT THIS TIME HE DIRECTED ME TO GO OUTSIDE TO THE FUELING PANEL ON THE UNDERSIDE OF THE WING AND TAKE A LOOK THERE. HOWEVER, MY ACTIONS OUTSIDE THE ACFT ALERTED THE MECH, WHO MET ME AS I WALKED BACK TOWARDS THE COCKPIT. HE ASKED ME WHAT THE PROB WAS. I INFORMED HIM THAT WE WERE HAVING A PROB VERIFYING HOW MUCH FUEL WAS ON THE AIRPLANE. HE STATED THAT HE HAD FUELED THAT TANK AND IT WAS TOPPED OFF. I FURTHER EMPHASIZED THE FACT THAT OUR CALCULATIONS SHOWED THAT WE WERE 700 GALLONS SHORT OF FUEL. HE RESTATED THAT HE WAS POSITIVE THE TANK WAS FULL OF FUEL. DURING THE ENSURING FLT, I OBSERVED NO INDICATIONS THAT EVER CAUSED ME TO DOUBT THAT OUR PREVIOUS CONCLUSIONS CONCERNING THE 700 GALLONS OF FUEL WERE NOT VALID. IT WAS DURING OUR REFUELING PROC THAT THE FIRST INDICATION OF A PROB AROSE. NO MATTER HOW WE CONFIGURED THE FUEL SYS, WE COULD NOT SEEM TO GET MUCH FUEL OUT OF TANK #3. AFTER NUMEROUS SYS CHKS AND A DRIPSTICK OF TANK #3, WE DETERMINED THAT THE TANK HAD BEEN VERY NEARLY EMPTY WHEN WE SHUT THE ENG DOWN AT THE GATE. AT THIS POINT, WE DECIDED TO FILL THIS NOW VERIFIED EMPTY TANK FROM THE TRUCK AND DETERMINE A KNOWN QUANTITY IN IT BY CHKING IT AGAINST THE METER ON THE TRUCK. WE EXPECTED A TOTAL OF APPROX 1717 GALLONS. AT THIS TIME, BOTH THE FO AND MYSELF WERE OBSERVING THE FUELING OP BY THE TRUCK. AT 1054 GALLONS THE VOLUMETRIC TOP OFF SYS ERRONEOUSLY CLOSED THE FUELING VALVE. THE MECH THEN CHKED THE DRIPSTICK AND STATED THAT THE TANK WAS NOT FULL. HE RESET THE SYS AND FUELING WAS RESUMED. I CONTINUED TO OBSERVE THE FUELING OP UNTIL THE VOLUMETRIC TOP OFF SYS AGAIN STOPPED FUELING. THIS TIME, HOWEVER, THE METER INDICATED 1717 GALLONS. THIS MATCHED THE KNOWN QUANTITY WE EXPECTED TO PUMP INTO THE TANK. THE TOTAL FUEL UPLIFT CALCULATIONS VERIFIED THIS. WE WERE NOW SATISFIED THAT WE HAD THE PROPER AMOUNT OF FUEL AT THIS TIME. THE REMAINDER OF THE TRIP PROCEEDED WITHOUT INCIDENT. OUR COMPANY POLICIES STATE THAT MAINT IS RESPONSIBLE FOR VERIFYING THE FUEL LOAD IN THE TANK WITH THE INOP FUEL GAUGE. IT APPEARS OBVIOUS THAT THEY WERE NOT THOROUGH IN THEIR DUTIES AND WERE FOOLED BY A FAULTY VOLUMETRIC TOP OFF INDICATION, WHICH STOPPED FUELING TO THAT TANK APPROX 700 GALLONS SHORT OF FULL. PROPER ACTION BY THE FLC COULD HAVE PREVENTED THIS INCIDENT, HOWEVER. THE FUEL QUANTITY CHK I HAD PERFORMED EARLIER GAVE US SOME INDICATION THAT THERE WAS A PROB. WHENEVER A CONTRADICTION SUCH AS THIS OCCURS, IT IS THE DUTY OF THE FLC TO NOW VERIFY IT FOR THEMSELVES. THAT WOULD HAVE PREVENTED THIS INCIDENT.
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.