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Attributes | |
ACN | 466380 |
Time | |
Date | 200003 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : zuric |
State Reference | HI |
Altitude | msl bound lower : 30000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zoa.artcc |
Make Model Name | DC-10 40 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : level |
Route In Use | enroute : pacific enroute airway : a331.airway |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 170 flight time total : 14000 flight time type : 4200 |
ASRS Report | 466380 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 210 flight time total : 8200 flight time type : 420 |
ASRS Report | 466379 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : overcame equipment problem flight crew : returned to assigned altitude flight crew : took precautionary avoidance action |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
1 hour after takeoff, level FL350, between zuric and zaale on A331, engine #2 flamed out due to fuel starvation. We turned left to clear the airway and descended to FL300 where a normal airstart was accomplished. We returned to FL350 and rejoined A331, sfo commercial radio was advised of everything and everything was done with their and oakland oceanic's knowledge. Supplemental information from acn 466651: 2 abnormalities existed in the fuel system: 1) aircraft dispatched with an MEL for #2 main tank fill valve inoperative. Procedure included direction to xfeed fuel in order to maintain balance (in lieu of normal fuel xfer). 2) fuel fill valves on operative tanks #1 and #3 failed to automatic-shut off at normal point during routine fuel xfer, rendering #2 tank level somewhat less than #1 and #3 (a previously unknown malfunction). In accordance with MEL, corrective action was xfeed of fuel from tanks #1 and #3 to all 3 engines, while ceasing fuel feed from tank #2 to engine #2. Small flashlight was placed on #2 tank fuel switch guard (with switches off) as a reminder of xfeed in progress. When all tank levels were balanced, I proceeded to end the fuel xfeed. My intention was to lift the flashlight off the switch guard and turn on 2 fuel pumps to reestablish pressure/fuel feed from #2 tank to #2 engine. I failed to turn the switches on. The next step was to close the #2 xfeed valve. Due to lack of positive fuel pressure, the #2 engine immediately flamed out. Fatigue (it was about XA00 'body time') and a possible distraction likely contributed to my failure to operate the fuel system as I intended. I believe any cockpit action that could affect engine operation should be observed/confirmed by a second crew member. My policy in the future will be to solicit 'observation' from the captain, and mutual agreement prior to initiating or ceasing engine #2 xfeeds.
Original NASA ASRS Text
Title: ENG FAILURE OVER THE PACIFIC WHEN FUEL IS MANAGED IMPROPERLY ON A DC10-40.
Narrative: 1 HR AFTER TKOF, LEVEL FL350, BTWN ZURIC AND ZAALE ON A331, ENG #2 FLAMED OUT DUE TO FUEL STARVATION. WE TURNED L TO CLR THE AIRWAY AND DSNDED TO FL300 WHERE A NORMAL AIRSTART WAS ACCOMPLISHED. WE RETURNED TO FL350 AND REJOINED A331, SFO COMMERCIAL RADIO WAS ADVISED OF EVERYTHING AND EVERYTHING WAS DONE WITH THEIR AND OAKLAND OCEANIC'S KNOWLEDGE. SUPPLEMENTAL INFO FROM ACN 466651: 2 ABNORMALITIES EXISTED IN THE FUEL SYS: 1) ACFT DISPATCHED WITH AN MEL FOR #2 MAIN TANK FILL VALVE INOP. PROC INCLUDED DIRECTION TO XFEED FUEL IN ORDER TO MAINTAIN BAL (IN LIEU OF NORMAL FUEL XFER). 2) FUEL FILL VALVES ON OPERATIVE TANKS #1 AND #3 FAILED TO AUTO-SHUT OFF AT NORMAL POINT DURING ROUTINE FUEL XFER, RENDERING #2 TANK LEVEL SOMEWHAT LESS THAN #1 AND #3 (A PREVIOUSLY UNKNOWN MALFUNCTION). IN ACCORDANCE WITH MEL, CORRECTIVE ACTION WAS XFEED OF FUEL FROM TANKS #1 AND #3 TO ALL 3 ENGS, WHILE CEASING FUEL FEED FROM TANK #2 TO ENG #2. SMALL FLASHLIGHT WAS PLACED ON #2 TANK FUEL SWITCH GUARD (WITH SWITCHES OFF) AS A REMINDER OF XFEED IN PROGRESS. WHEN ALL TANK LEVELS WERE BALANCED, I PROCEEDED TO END THE FUEL XFEED. MY INTENTION WAS TO LIFT THE FLASHLIGHT OFF THE SWITCH GUARD AND TURN ON 2 FUEL PUMPS TO REESTABLISH PRESSURE/FUEL FEED FROM #2 TANK TO #2 ENGINE. I FAILED TO TURN THE SWITCHES ON. THE NEXT STEP WAS TO CLOSE THE #2 XFEED VALVE. DUE TO LACK OF POSITIVE FUEL PRESSURE, THE #2 ENG IMMEDIATELY FLAMED OUT. FATIGUE (IT WAS ABOUT XA00 'BODY TIME') AND A POSSIBLE DISTR LIKELY CONTRIBUTED TO MY FAILURE TO OPERATE THE FUEL SYS AS I INTENDED. I BELIEVE ANY COCKPIT ACTION THAT COULD AFFECT ENG OP SHOULD BE OBSERVED/CONFIRMED BY A SECOND CREW MEMBER. MY POLICY IN THE FUTURE WILL BE TO SOLICIT 'OBSERVATION' FROM THE CAPT, AND MUTUAL AGREEMENT PRIOR TO INITIATING OR CEASING ENG #2 XFEEDS.
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.