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|
Attributes | |
ACN | 530341 |
Time | |
Date | 200111 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sea.airport |
State Reference | WA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : pushback |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp pilot : cfi pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 200 flight time total : 10700 flight time type : 3800 |
ASRS Report | 530341 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | other other |
Supplementary | |
Problem Areas | Maintenance Human Performance Flight Crew Human Performance Company Aircraft Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
Release paperwork required 23100 pounds fuel minimum for flight. Arrived at aircraft and received fuel slip from fueler showing 23100 pounds fuel loaded on aircraft. Looked at fuel gauges and 'saw' 23100 pounds. Actual fuel on board (and showing on gauges) was 20100 pounds, 3000 pounds short. Ran 'before start' checklist and read back 23100 pounds, misreading fuel gauges again. After pushback and engine start we received load numbers from station operations and discovered fuel total discrepancy. Taxi back to gate and fueled to correct quantity then departed normally. Several factors were at play here. It started with the fueling personnel misreading the gauges at the fueling station and shorting us 3000 pounds of fuel, but showing on the fuel slip that the correct amount was uplifted. Another factor was waiting for dispatch to send us a new release with a new routing (due to en route turbulence). Although the fuel required was the same amount (23100 pounds), getting the new flight plan and release at the last moment and having to reprogram the FMS at the last moment lead to rushing the 'before start' checklist and missing the (incorrect) fuel quantity. One last factor was that I have been flying the B737-400 almost exclusively for the last few months and in that model the main tanks hold 10000 pounds each with anything over 20000 pounds going into the center tank. When I saw 3100 pounds showing on the center gauge I subconsciously imagined we had 23100 pounds total. On the -900 series I was flying on nov/sat/01, the mains hold 8500 pounds each and the extra going into the center. This left me 3000 pounds short (8500 pounds X 2 = 17000 pounds -20000 pounds = 3000 pounds short). There were several checks to detect the error prior to being airborne and it was the last one that caught it. The first officer inputting the load numbers from operations into the FMC and noticing the takeoff weight discrepancy. To prevent this in the future I intend to read the fuel gauges carefully and deliberately.
Original NASA ASRS Text
Title: A B737-900 FLC PUSHES BACK FOR DEP AFTER READING THE WRONG FUEL LOAD ON THEIR FUEL GAUGES DURING THEIR CHKLIST USE AT SEA, WA.
Narrative: RELEASE PAPERWORK REQUIRED 23100 LBS FUEL MINIMUM FOR FLT. ARRIVED AT ACFT AND RECEIVED FUEL SLIP FROM FUELER SHOWING 23100 LBS FUEL LOADED ON ACFT. LOOKED AT FUEL GAUGES AND 'SAW' 23100 LBS. ACTUAL FUEL ON BOARD (AND SHOWING ON GAUGES) WAS 20100 LBS, 3000 LBS SHORT. RAN 'BEFORE START' CHKLIST AND READ BACK 23100 LBS, MISREADING FUEL GAUGES AGAIN. AFTER PUSHBACK AND ENG START WE RECEIVED LOAD NUMBERS FROM STATION OPS AND DISCOVERED FUEL TOTAL DISCREPANCY. TAXI BACK TO GATE AND FUELED TO CORRECT QUANTITY THEN DEPARTED NORMALLY. SEVERAL FACTORS WERE AT PLAY HERE. IT STARTED WITH THE FUELING PERSONNEL MISREADING THE GAUGES AT THE FUELING STATION AND SHORTING US 3000 LBS OF FUEL, BUT SHOWING ON THE FUEL SLIP THAT THE CORRECT AMOUNT WAS UPLIFTED. ANOTHER FACTOR WAS WAITING FOR DISPATCH TO SEND US A NEW RELEASE WITH A NEW ROUTING (DUE TO ENRTE TURB). ALTHOUGH THE FUEL REQUIRED WAS THE SAME AMOUNT (23100 LBS), GETTING THE NEW FLT PLAN AND RELEASE AT THE LAST MOMENT AND HAVING TO REPROGRAM THE FMS AT THE LAST MOMENT LEAD TO RUSHING THE 'BEFORE START' CHKLIST AND MISSING THE (INCORRECT) FUEL QUANTITY. ONE LAST FACTOR WAS THAT I HAVE BEEN FLYING THE B737-400 ALMOST EXCLUSIVELY FOR THE LAST FEW MONTHS AND IN THAT MODEL THE MAIN TANKS HOLD 10000 LBS EACH WITH ANYTHING OVER 20000 LBS GOING INTO THE CTR TANK. WHEN I SAW 3100 LBS SHOWING ON THE CTR GAUGE I SUBCONSCIOUSLY IMAGINED WE HAD 23100 LBS TOTAL. ON THE -900 SERIES I WAS FLYING ON NOV/SAT/01, THE MAINS HOLD 8500 LBS EACH AND THE EXTRA GOING INTO THE CTR. THIS LEFT ME 3000 LBS SHORT (8500 LBS X 2 = 17000 LBS -20000 LBS = 3000 LBS SHORT). THERE WERE SEVERAL CHKS TO DETECT THE ERROR PRIOR TO BEING AIRBORNE AND IT WAS THE LAST ONE THAT CAUGHT IT. THE FO INPUTTING THE LOAD NUMBERS FROM OPS INTO THE FMC AND NOTICING THE TKOF WT DISCREPANCY. TO PREVENT THIS IN THE FUTURE I INTEND TO READ THE FUEL GAUGES CAREFULLY AND DELIBERATELY.
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.