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|
Attributes | |
ACN | 521565 |
Time | |
Date | 200108 |
Day | Mon |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | intersection : ebber |
State Reference | HI |
Altitude | msl bound lower : 38000 msl bound upper : 39000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | artcc : zhn.artcc |
Operator | common carrier : air carrier |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 11300 flight time type : 2000 |
ASRS Report | 521565 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : flight engineer pilot : commercial pilot : cfi pilot : atp pilot : instrument |
Experience | flight time last 90 days : 20 flight time total : 7000 flight time type : 747 |
ASRS Report | 521558 |
Events | |
Anomaly | aircraft equipment problem : critical non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Climbing through FL380 to FL390 the #1 engine was noted surging and losing power. Configuring fuel panel to emergency feed (all pumps on, xfeeds open) and engine ignition to 'on' was followed by stabilization of #1 engine. Immediately following this, the #4 engine showed the same symptoms, although it would not accelerate beyond idle. Restart procedures were followed with a successful outcome and the flight continued normally. Discussion with the so revealed his inadvertent closing of the #1 and #4 xfeeds and shutting off those associated fuel pumps. His workload at the time was moderate, fatigue certainly was an issue, and haste to keep the fuel system balanced resulted in his hurried mistake. Although this flight was preceded by 48 hours rest, fatigue was certainly an issue. Hotel departure time was XA30 am, hotel noise and attempting sleep during daylight hours make more than a few hours rest prior to this departure difficult. Solutions to this particular fatigue problem are limited to perhaps a quieter hotel. Solutions to inadvertent fuel panel operation are more difficult, when able it may be helpful for the so to notify the captain when changing fuel panel confign.
Original NASA ASRS Text
Title: B747 CREW HAD A SPOOL DOWN OF ENGS #1 AND #4 IN ZOA PACIFIC OP.
Narrative: CLBING THROUGH FL380 TO FL390 THE #1 ENG WAS NOTED SURGING AND LOSING PWR. CONFIGURING FUEL PANEL TO EMER FEED (ALL PUMPS ON, XFEEDS OPEN) AND ENG IGNITION TO 'ON' WAS FOLLOWED BY STABILIZATION OF #1 ENG. IMMEDIATELY FOLLOWING THIS, THE #4 ENG SHOWED THE SAME SYMPTOMS, ALTHOUGH IT WOULD NOT ACCELERATE BEYOND IDLE. RESTART PROCS WERE FOLLOWED WITH A SUCCESSFUL OUTCOME AND THE FLT CONTINUED NORMALLY. DISCUSSION WITH THE SO REVEALED HIS INADVERTENT CLOSING OF THE #1 AND #4 XFEEDS AND SHUTTING OFF THOSE ASSOCIATED FUEL PUMPS. HIS WORKLOAD AT THE TIME WAS MODERATE, FATIGUE CERTAINLY WAS AN ISSUE, AND HASTE TO KEEP THE FUEL SYS BALANCED RESULTED IN HIS HURRIED MISTAKE. ALTHOUGH THIS FLT WAS PRECEDED BY 48 HRS REST, FATIGUE WAS CERTAINLY AN ISSUE. HOTEL DEP TIME WAS XA30 AM, HOTEL NOISE AND ATTEMPTING SLEEP DURING DAYLIGHT HRS MAKE MORE THAN A FEW HRS REST PRIOR TO THIS DEP DIFFICULT. SOLUTIONS TO THIS PARTICULAR FATIGUE PROB ARE LIMITED TO PERHAPS A QUIETER HOTEL. SOLUTIONS TO INADVERTENT FUEL PANEL OP ARE MORE DIFFICULT, WHEN ABLE IT MAY BE HELPFUL FOR THE SO TO NOTIFY THE CAPT WHEN CHANGING FUEL PANEL CONFIGN.
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.