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|
Attributes | |
ACN | 499853 |
Time | |
Date | 200101 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | navaid : oal.vortac |
State Reference | NV |
Altitude | msl single value : 31000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zlc.artcc |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 2000 |
ASRS Report | 499853 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Cabin Crew Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was manually xfeeding fuel at cruise altitude when I became distraction, forgetting about this xfeed operation until a significant imbal developed -- approximately 1800 pounds out of balance, 800 pounds over limit. We corrected the problem prior to top of descent and remainder of flight was normal. Autoflt was correcting for the imbal. However, I did not notice the slow change in bank angle toward the light side. I had begun the xfeed while the first officer was out of the cockpit (in the lavatory) and I'm not sure I told him I was xfeeding. The flight attendant followed the first officer into the cockpit. With putting away the mask, talking with her and subsequently putting away departure plates and looking over approach plates, I completely forgot about the xfeed -- probably +/-30 mins. Contributing to my inattn, I had failed to use a 'reminder.' usually I attach my identify badge to the yoke. I think fatigue played a role in deviating from my normal habit pattern. In addition, I was wearing 'reading' glasses -- something I hadn't done much before. While I reviewed the approach, the glasses are good for reading, but blurred the instrument panel. All of these factors played their small roles in this event. But I think fatigue was the biggest. It had been a long day already and I was not very alert. Things I plan to do differently: 1) always inform first officer of xfeed. 2) when an obvious distraction presents itself, terminate xfeed and return to it when the distraction -- whatever it is -- is gone. 3) always use a reminder -- perhaps a more visible one as well -- for dimly lit cockpits at night. 4) be alert for fatigue. Obviously, I hadn't scanned the instrument panel in close to 30 mins! 5) get some of those smaller, 1/2 size 'readers' that D not obstruct vision above mid level.
Original NASA ASRS Text
Title: MLG CAPT ALLOWED THE FUEL CROSS SHIP BAL TO EXCEED ACFT LIMITATIONS IN ZLC CLASS A AIRSPACE.
Narrative: I WAS MANUALLY XFEEDING FUEL AT CRUISE ALT WHEN I BECAME DISTR, FORGETTING ABOUT THIS XFEED OP UNTIL A SIGNIFICANT IMBAL DEVELOPED -- APPROX 1800 LBS OUT OF BAL, 800 LBS OVER LIMIT. WE CORRECTED THE PROB PRIOR TO TOP OF DSCNT AND REMAINDER OF FLT WAS NORMAL. AUTOFLT WAS CORRECTING FOR THE IMBAL. HOWEVER, I DID NOT NOTICE THE SLOW CHANGE IN BANK ANGLE TOWARD THE LIGHT SIDE. I HAD BEGUN THE XFEED WHILE THE FO WAS OUT OF THE COCKPIT (IN THE LAVATORY) AND I'M NOT SURE I TOLD HIM I WAS XFEEDING. THE FLT ATTENDANT FOLLOWED THE FO INTO THE COCKPIT. WITH PUTTING AWAY THE MASK, TALKING WITH HER AND SUBSEQUENTLY PUTTING AWAY DEP PLATES AND LOOKING OVER APCH PLATES, I COMPLETELY FORGOT ABOUT THE XFEED -- PROBABLY +/-30 MINS. CONTRIBUTING TO MY INATTN, I HAD FAILED TO USE A 'REMINDER.' USUALLY I ATTACH MY IDENT BADGE TO THE YOKE. I THINK FATIGUE PLAYED A ROLE IN DEVIATING FROM MY NORMAL HABIT PATTERN. IN ADDITION, I WAS WEARING 'READING' GLASSES -- SOMETHING I HADN'T DONE MUCH BEFORE. WHILE I REVIEWED THE APCH, THE GLASSES ARE GOOD FOR READING, BUT BLURRED THE INST PANEL. ALL OF THESE FACTORS PLAYED THEIR SMALL ROLES IN THIS EVENT. BUT I THINK FATIGUE WAS THE BIGGEST. IT HAD BEEN A LONG DAY ALREADY AND I WAS NOT VERY ALERT. THINGS I PLAN TO DO DIFFERENTLY: 1) ALWAYS INFORM FO OF XFEED. 2) WHEN AN OBVIOUS DISTR PRESENTS ITSELF, TERMINATE XFEED AND RETURN TO IT WHEN THE DISTR -- WHATEVER IT IS -- IS GONE. 3) ALWAYS USE A REMINDER -- PERHAPS A MORE VISIBLE ONE AS WELL -- FOR DIMLY LIT COCKPITS AT NIGHT. 4) BE ALERT FOR FATIGUE. OBVIOUSLY, I HADN'T SCANNED THE INST PANEL IN CLOSE TO 30 MINS! 5) GET SOME OF THOSE SMALLER, 1/2 SIZE 'READERS' THAT D NOT OBSTRUCT VISION ABOVE MID LEVEL.
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.