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|
Attributes | |
ACN | 476756 |
Time | |
Date | 200006 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : takeoff roll ground : position and hold ground : holding |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 6600 flight time type : 300 |
ASRS Report | 476756 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : company policies non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : fuel confign light |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Aircraft Airport |
Primary Problem | Flight Crew Human Performance |
Narrative:
On taxi out from dca (en route to ord), we got into the visual 'taxiway gridlock,' our fuel on taxi out was slightly out of balance, so the captain elected to xfeed fuel to balance the left and right tanks. We were cleared into position for takeoff and when I pushed the 'EICAS recall' button, the yellow annunciations indicated we were still in a 'xfeed' situation. I brought this attention to the captain, who promptly placed all boost pumps 'on' or so I thought. Dca tower cleared us for an immediate takeoff. Takeoff and climb out were normal, until climbing through about 20000 ft, when the (fuel confign) light came on. One of the center tank boost pumps had not been turned on, and we were now 1900 pounds out of fuel balance (the aircraft limitation is 1000 pounds). We promptly corrected the situation by xfeeding. No abnormal flight characteristics were noted. Several things contributed to our mistake: 1) overload. Taxiway gridlock, a complicated noise abatement takeoff and track, and preoccupation with taxiing around other aircraft. 2) our immediate takeoff clearance. Aircraft on short final behind us. We were rushed. 3) darkness (the cockpit was dark). 4) the design of the switch. The boost pump switches require enough pressure to 'lock in.' enough pressure wasn't used (I'm confident the captain did push the switch, but it didn't lock in. 5) and the most important reason of all -- the 'fuel confign' light comes on at 1800 pounds of fuel imbalance, while the aircraft limitation is 1000 pounds. By the time the light illuminates, the aircraft has already exceeded the limitation. How dumb. I think I learned a lot from our mistake, including pressing the EICAS recall button after all switches are moved, as well as perhaps being much more in tune when other crew members move switches.
Original NASA ASRS Text
Title: A B757 FLC TAKES OFF WITH ONE OF THEIR CTR TANK BOOST PUMPS IN THE OFF POS, CREATING AN IMBALANCED FUEL CONDITION AFTER TKOF FROM DCA, DC.
Narrative: ON TAXI OUT FROM DCA (ENRTE TO ORD), WE GOT INTO THE VISUAL 'TXWY GRIDLOCK,' OUR FUEL ON TAXI OUT WAS SLIGHTLY OUT OF BAL, SO THE CAPT ELECTED TO XFEED FUEL TO BAL THE L AND R TANKS. WE WERE CLRED INTO POS FOR TKOF AND WHEN I PUSHED THE 'EICAS RECALL' BUTTON, THE YELLOW ANNUNCIATIONS INDICATED WE WERE STILL IN A 'XFEED' SIT. I BROUGHT THIS ATTN TO THE CAPT, WHO PROMPTLY PLACED ALL BOOST PUMPS 'ON' OR SO I THOUGHT. DCA TWR CLRED US FOR AN IMMEDIATE TKOF. TKOF AND CLBOUT WERE NORMAL, UNTIL CLBING THROUGH ABOUT 20000 FT, WHEN THE (FUEL CONFIGN) LIGHT CAME ON. ONE OF THE CTR TANK BOOST PUMPS HAD NOT BEEN TURNED ON, AND WE WERE NOW 1900 LBS OUT OF FUEL BAL (THE ACFT LIMITATION IS 1000 LBS). WE PROMPTLY CORRECTED THE SIT BY XFEEDING. NO ABNORMAL FLT CHARACTERISTICS WERE NOTED. SEVERAL THINGS CONTRIBUTED TO OUR MISTAKE: 1) OVERLOAD. TXWY GRIDLOCK, A COMPLICATED NOISE ABATEMENT TKOF AND TRACK, AND PREOCCUPATION WITH TAXIING AROUND OTHER ACFT. 2) OUR IMMEDIATE TKOF CLRNC. ACFT ON SHORT FINAL BEHIND US. WE WERE RUSHED. 3) DARKNESS (THE COCKPIT WAS DARK). 4) THE DESIGN OF THE SWITCH. THE BOOST PUMP SWITCHES REQUIRE ENOUGH PRESSURE TO 'LOCK IN.' ENOUGH PRESSURE WASN'T USED (I'M CONFIDENT THE CAPT DID PUSH THE SWITCH, BUT IT DIDN'T LOCK IN. 5) AND THE MOST IMPORTANT REASON OF ALL -- THE 'FUEL CONFIGN' LIGHT COMES ON AT 1800 LBS OF FUEL IMBALANCE, WHILE THE ACFT LIMITATION IS 1000 LBS. BY THE TIME THE LIGHT ILLUMINATES, THE ACFT HAS ALREADY EXCEEDED THE LIMITATION. HOW DUMB. I THINK I LEARNED A LOT FROM OUR MISTAKE, INCLUDING PRESSING THE EICAS RECALL BUTTON AFTER ALL SWITCHES ARE MOVED, AS WELL AS PERHAPS BEING MUCH MORE IN TUNE WHEN OTHER CREW MEMBERS MOVE SWITCHES.
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.