Narrative:

Dispatched with 'fuel quantity fault' as maintenance item. On this airplane, this means 2 pages of MEL items, several inoperative items including the particular fuel tank quantity (tank #2 in this case), total fuel aboard and gross weight. The formerly automatic system is now operated in manual mode. Fuel aboard is to be determined by maintenance and fuel people and the crew informed of exactly how much fuel is aboard and its distribution. After start, fuel aboard is determined by subtracting fuel used readings from total fuel aboard at start. Our flight plan required 93000 pounds total and our fuel service form showed a total of 93011 pounds with 29,400 pounds in #1, 32511 in #2, and 29,400 pounds in #3. At approximately 2 hours 10 mins into flight, received 'tank #2 pumps low' alert. All tank pumps shown on schematic display were cycling on and off. Very confusing data as obviously fuel in the tank and we figured must be some sort of electronic malfunction sending erratic information to the pumps. Shortly thereafter, #2 engine flamed out. This did not make sense, as obviously fuel in tank plus never received a 'fuel quantity low' alert if truly low in fuel. Restart attempt unsuccessful. Went to lower altitude, declared emergency, decided to continue to taipei after considering fuel aboard and 2 good engines operating. Then attempted to xfer fuel from #2 to other running engine tanks -- unable. So now low fuel estimate at landing. Got priority handling. Ran all checklists and made successful 2 engine landing. After parking, requested maintenance check fuel. Found #2 tank empty. Current analysis is that initial fueling was probably done in liters, even though fuel service form showed gallons and pounds. While tanks #1 and #3 showed correct fuel to crew, #2 tank gauge and totalizer were inoperative so crew was forced to take the word of maintenance/refuel personnel plus what was written on the fuel service form! In this case, it was incorrect. Additional factors to consider: 1) should not dispatch this airplane with inoperative fuel gauges, totalizer and weight readings inoperative. 2) this 2 pilot airplane gets complex and hectic when confusing and conflicting data presented and multiple activities are required. 3) consideration should be given to never dispatching this airplane with a manual system as loss of other automatic system can occur and, in emergency situation, takes 2 people to the limit! 4) my company has just introduced new checklists and, when I asked the copilot for the '1 engine inoperative approach and landing checklist' I was told there was 'no such checklist.' there was, but it has been removed from the new format and included in 'engine fire or severe damage' checklist! 5) I was conducting IOE for the copilot. To say that the cockpit was at a 'fever pitch' would be to grossly understate! 6) our new 'electronic airplanes' can, and do, generate confusing and conflicting information. In this case, we 'knew' we had fuel in the #2 tank as we never received a 'fuel quantity low' alert, so the situation made no sense and we initially were led to the conclusion we had some unusual pump or tank problem. Now we are told that with #2 tank quantity inoperative, the 'fuel quantity low' alert is also disabled, which was new to everyone! Which brings us back to item #1: when one item being inoperative causes so many other things to fail, we need to rethink dispatching the airplane with such inoperative. To be discovering 'new' engineering and design features (flaws?) after yrs of operation is not encouraging! Callback conversation with reporter revealed the following information: the captain is a highly experienced line check airman with his air carrier. The flight was on an rjaa to rctp leg with a deferred #2 fuel quantity inoperative. This creates a multitude of flight procedure changes, the least of which is being dependent on the fueler for correct fuel quantity loading. The company does not require a 'stick' reading to determine the total loaded fuel quantity. If the fueler misfuels the aircraft, there is no way to detect the error. The captain was debriefed by the company, but as of this date it has not seen fit to respond to any of the captain's recommendations. The captain also stated that refusal to fly with a deferred item was grounds for being fired. With this kind of company attitude the captain thinks the FAA needs to reconsider the ability to allow flight with inoperative fuel quantity system and recommend the master MEL be changed accordingly.

Related reports:

Google
 

Original NASA ASRS Text

Title: MD11 CREW HAD #2 ENG FAIL BECAUSE OF FUEL STARVATION IN RCTP CLASS A AIRSPACE.

Narrative: DISPATCHED WITH 'FUEL QUANTITY FAULT' AS MAINT ITEM. ON THIS AIRPLANE, THIS MEANS 2 PAGES OF MEL ITEMS, SEVERAL INOP ITEMS INCLUDING THE PARTICULAR FUEL TANK QUANTITY (TANK #2 IN THIS CASE), TOTAL FUEL ABOARD AND GROSS WT. THE FORMERLY AUTOMATIC SYS IS NOW OPERATED IN MANUAL MODE. FUEL ABOARD IS TO BE DETERMINED BY MAINT AND FUEL PEOPLE AND THE CREW INFORMED OF EXACTLY HOW MUCH FUEL IS ABOARD AND ITS DISTRIBUTION. AFTER START, FUEL ABOARD IS DETERMINED BY SUBTRACTING FUEL USED READINGS FROM TOTAL FUEL ABOARD AT START. OUR FLT PLAN REQUIRED 93000 LBS TOTAL AND OUR FUEL SVC FORM SHOWED A TOTAL OF 93011 LBS WITH 29,400 LBS IN #1, 32511 IN #2, AND 29,400 LBS IN #3. AT APPROX 2 HRS 10 MINS INTO FLT, RECEIVED 'TANK #2 PUMPS LOW' ALERT. ALL TANK PUMPS SHOWN ON SCHEMATIC DISPLAY WERE CYCLING ON AND OFF. VERY CONFUSING DATA AS OBVIOUSLY FUEL IN THE TANK AND WE FIGURED MUST BE SOME SORT OF ELECTRONIC MALFUNCTION SENDING ERRATIC INFO TO THE PUMPS. SHORTLY THEREAFTER, #2 ENG FLAMED OUT. THIS DID NOT MAKE SENSE, AS OBVIOUSLY FUEL IN TANK PLUS NEVER RECEIVED A 'FUEL QUANTITY LOW' ALERT IF TRULY LOW IN FUEL. RESTART ATTEMPT UNSUCCESSFUL. WENT TO LOWER ALT, DECLARED EMER, DECIDED TO CONTINUE TO TAIPEI AFTER CONSIDERING FUEL ABOARD AND 2 GOOD ENGS OPERATING. THEN ATTEMPTED TO XFER FUEL FROM #2 TO OTHER RUNNING ENG TANKS -- UNABLE. SO NOW LOW FUEL ESTIMATE AT LNDG. GOT PRIORITY HANDLING. RAN ALL CHKLISTS AND MADE SUCCESSFUL 2 ENG LNDG. AFTER PARKING, REQUESTED MAINT CHK FUEL. FOUND #2 TANK EMPTY. CURRENT ANALYSIS IS THAT INITIAL FUELING WAS PROBABLY DONE IN LITERS, EVEN THOUGH FUEL SVC FORM SHOWED GALLONS AND LBS. WHILE TANKS #1 AND #3 SHOWED CORRECT FUEL TO CREW, #2 TANK GAUGE AND TOTALIZER WERE INOP SO CREW WAS FORCED TO TAKE THE WORD OF MAINT/REFUEL PERSONNEL PLUS WHAT WAS WRITTEN ON THE FUEL SVC FORM! IN THIS CASE, IT WAS INCORRECT. ADDITIONAL FACTORS TO CONSIDER: 1) SHOULD NOT DISPATCH THIS AIRPLANE WITH INOP FUEL GAUGES, TOTALIZER AND WT READINGS INOP. 2) THIS 2 PLT AIRPLANE GETS COMPLEX AND HECTIC WHEN CONFUSING AND CONFLICTING DATA PRESENTED AND MULTIPLE ACTIVITIES ARE REQUIRED. 3) CONSIDERATION SHOULD BE GIVEN TO NEVER DISPATCHING THIS AIRPLANE WITH A MANUAL SYS AS LOSS OF OTHER AUTOMATIC SYS CAN OCCUR AND, IN EMER SIT, TAKES 2 PEOPLE TO THE LIMIT! 4) MY COMPANY HAS JUST INTRODUCED NEW CHKLISTS AND, WHEN I ASKED THE COPLT FOR THE '1 ENG INOP APCH AND LNDG CHKLIST' I WAS TOLD THERE WAS 'NO SUCH CHKLIST.' THERE WAS, BUT IT HAS BEEN REMOVED FROM THE NEW FORMAT AND INCLUDED IN 'ENG FIRE OR SEVERE DAMAGE' CHKLIST! 5) I WAS CONDUCTING IOE FOR THE COPLT. TO SAY THAT THE COCKPIT WAS AT A 'FEVER PITCH' WOULD BE TO GROSSLY UNDERSTATE! 6) OUR NEW 'ELECTRONIC AIRPLANES' CAN, AND DO, GENERATE CONFUSING AND CONFLICTING INFO. IN THIS CASE, WE 'KNEW' WE HAD FUEL IN THE #2 TANK AS WE NEVER RECEIVED A 'FUEL QUANTITY LOW' ALERT, SO THE SIT MADE NO SENSE AND WE INITIALLY WERE LED TO THE CONCLUSION WE HAD SOME UNUSUAL PUMP OR TANK PROB. NOW WE ARE TOLD THAT WITH #2 TANK QUANTITY INOP, THE 'FUEL QUANTITY LOW' ALERT IS ALSO DISABLED, WHICH WAS NEW TO EVERYONE! WHICH BRINGS US BACK TO ITEM #1: WHEN ONE ITEM BEING INOP CAUSES SO MANY OTHER THINGS TO FAIL, WE NEED TO RETHINK DISPATCHING THE AIRPLANE WITH SUCH INOP. TO BE DISCOVERING 'NEW' ENGINEERING AND DESIGN FEATURES (FLAWS?) AFTER YRS OF OP IS NOT ENCOURAGING! CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT IS A HIGHLY EXPERIENCED LINE CHK AIRMAN WITH HIS ACR. THE FLT WAS ON AN RJAA TO RCTP LEG WITH A DEFERRED #2 FUEL QUANTITY INOP. THIS CREATES A MULTITUDE OF FLT PROC CHANGES, THE LEAST OF WHICH IS BEING DEPENDENT ON THE FUELER FOR CORRECT FUEL QUANTITY LOADING. THE COMPANY DOES NOT REQUIRE A 'STICK' READING TO DETERMINE THE TOTAL LOADED FUEL QUANTITY. IF THE FUELER MISFUELS THE ACFT, THERE IS NO WAY TO DETECT THE ERROR. THE CAPT WAS DEBRIEFED BY THE COMPANY, BUT AS OF THIS DATE IT HAS NOT SEEN FIT TO RESPOND TO ANY OF THE CAPT'S RECOMMENDATIONS. THE CAPT ALSO STATED THAT REFUSAL TO FLY WITH A DEFERRED ITEM WAS GNDS FOR BEING FIRED. WITH THIS KIND OF COMPANY ATTITUDE THE CAPT THINKS THE FAA NEEDS TO RECONSIDER THE ABILITY TO ALLOW FLT WITH INOP FUEL QUANTITY SYS AND RECOMMEND THE MASTER MEL BE CHANGED ACCORDINGLY.

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.