37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 458804 |
Time | |
Date | 199912 |
Day | Sun |
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 | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : parked ground : maintenance |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 11000 flight time type : 6500 |
ASRS Report | 458804 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 16000 flight time type : 10000 |
ASRS Report | 458805 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Factors | |
Maintenance | performance deficiency : non compliance with legal requirements performance deficiency : repair performance deficiency : testing |
Supplementary | |
Problem Areas | Aircraft Maintenance Human Performance |
Primary Problem | Maintenance Human Performance |
Narrative:
Maintenance had removed the flight engineer's digital gauge equipped fuel panel to fix a previous problem. After reinstallation, the flight engineer ran a full, first flight of the day test on the panel, and reported everything appeared normal. Fuel loads in all tanks were equal on our first leg, so the aircraft appeared normal in-flight, too. The second flight the next morning also started normally, including a normal first flight of the day fuel panel check. During climb out, the flight engineer encountered unusual digital fuel readouts while attempting to correct a minor imbal between #1 and #3 tanks. He also reported that the analog bar graph readout for the #3 tank was way out of line with the readings in the #1 tank. As a result, we suspected connections might have been switched between the #2 and #3 tank gauges. We made a quick check by opening all the xfeed manifold valves to see which gauge continued to drop. In this confign, with all pumps on, only the #2 tank would show a fuel burn. However, only the #3 tank indicated fuel was being burned. The captain then contacted company mechanics by radio and confirmed that it was possible to cross-connect the cannon plugs for the gauges and then get readings such as we were experiencing. Because the gauges appeared to be reading normally, but simply in reverse position, and because a preflight fueling safety check done by the fueler also indicated the gauges were reading reliably so that we had not been incorrectly fueled (due to an initially equal load in all tanks), the captain elected to continue to planned destination assuming the gauges were switched. We landed without further incident. After landing, maintenance personnel confirmed that the gauges had indeed been cross-connected. They also indicated to the captain that it would have been virtually impossible for the engineer to spot this problem so long south equal fuel loads were boarded. Actually, the flight engineer's quick in-flight initial analysis probably prevented a fuel out of balance condition on our flight and also prevented us from unknowingly passing this aircraft on to another unsuspecting crew.
Original NASA ASRS Text
Title: A B727-200 WAS DISPATCHED IN NON COMPLIANCE WITH FUEL QUANTITY INDICATORS FOR TANKS #2 AND #3 SWAPPED DURING MAINT.
Narrative: MAINT HAD REMOVED THE FE'S DIGITAL GAUGE EQUIPPED FUEL PANEL TO FIX A PREVIOUS PROB. AFTER REINSTALLATION, THE FE RAN A FULL, FIRST FLT OF THE DAY TEST ON THE PANEL, AND RPTED EVERYTHING APPEARED NORMAL. FUEL LOADS IN ALL TANKS WERE EQUAL ON OUR FIRST LEG, SO THE ACFT APPEARED NORMAL INFLT, TOO. THE SECOND FLT THE NEXT MORNING ALSO STARTED NORMALLY, INCLUDING A NORMAL FIRST FLT OF THE DAY FUEL PANEL CHK. DURING CLBOUT, THE FE ENCOUNTERED UNUSUAL DIGITAL FUEL READOUTS WHILE ATTEMPTING TO CORRECT A MINOR IMBAL BTWN #1 AND #3 TANKS. HE ALSO RPTED THAT THE ANALOG BAR GRAPH READOUT FOR THE #3 TANK WAS WAY OUT OF LINE WITH THE READINGS IN THE #1 TANK. AS A RESULT, WE SUSPECTED CONNECTIONS MIGHT HAVE BEEN SWITCHED BTWN THE #2 AND #3 TANK GAUGES. WE MADE A QUICK CHK BY OPENING ALL THE XFEED MANIFOLD VALVES TO SEE WHICH GAUGE CONTINUED TO DROP. IN THIS CONFIGN, WITH ALL PUMPS ON, ONLY THE #2 TANK WOULD SHOW A FUEL BURN. HOWEVER, ONLY THE #3 TANK INDICATED FUEL WAS BEING BURNED. THE CAPT THEN CONTACTED COMPANY MECHS BY RADIO AND CONFIRMED THAT IT WAS POSSIBLE TO CROSS-CONNECT THE CANNON PLUGS FOR THE GAUGES AND THEN GET READINGS SUCH AS WE WERE EXPERIENCING. BECAUSE THE GAUGES APPEARED TO BE READING NORMALLY, BUT SIMPLY IN REVERSE POS, AND BECAUSE A PREFLT FUELING SAFETY CHK DONE BY THE FUELER ALSO INDICATED THE GAUGES WERE READING RELIABLY SO THAT WE HAD NOT BEEN INCORRECTLY FUELED (DUE TO AN INITIALLY EQUAL LOAD IN ALL TANKS), THE CAPT ELECTED TO CONTINUE TO PLANNED DEST ASSUMING THE GAUGES WERE SWITCHED. WE LANDED WITHOUT FURTHER INCIDENT. AFTER LNDG, MAINT PERSONNEL CONFIRMED THAT THE GAUGES HAD INDEED BEEN CROSS-CONNECTED. THEY ALSO INDICATED TO THE CAPT THAT IT WOULD HAVE BEEN VIRTUALLY IMPOSSIBLE FOR THE ENGINEER TO SPOT THIS PROB SO LONG S EQUAL FUEL LOADS WERE BOARDED. ACTUALLY, THE FE'S QUICK INFLT INITIAL ANALYSIS PROBABLY PREVENTED A FUEL OUT OF BAL CONDITION ON OUR FLT AND ALSO PREVENTED US FROM UNKNOWINGLY PASSING THIS ACFT ON TO ANOTHER UNSUSPECTING CREW.
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.