37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 543287 |
Time | |
Date | 200203 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ewr.airport |
State Reference | NJ |
Altitude | msl single value : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air carrier |
Make Model Name | Jetstream 41 |
Operating Under FAR Part | Part 121 |
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 : 132 flight time total : 2900 flight time type : 250 |
ASRS Report | 543287 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 245 flight time total : 2250 flight time type : 1050 |
ASRS Report | 543792 |
Events | |
Anomaly | aircraft equipment problem : critical maintenance problem : improper maintenance non adherence : far other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : fuel gauges other flight crewa other flight crewb |
Resolutory Action | flight crew : diverted to another airport flight crew : landed as precaution |
Consequence | other Other |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance Company Maintenance Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
On the climb out, we determined that we had insufficient fuel to proceed to iad. We assessed the situation, notified ATC that we had minimum fuel on board and requested a diversion to ewr. ATC granted us clearance to ewr, which was VFR at the time, and we proceeded to land with a clearance for a visual approach. The landing was uneventful. We taxied to the gate, notified dispatch and were rereleased to iad. The flight from ewr to iad was normal. The first officer and I had flown 1 round trip together prior to this flight. We reported for duty at XA00 and a sufficient rest period. The first trip was also a round trip. During the turnaround, operations proceeded normally. We asked for ramp service, conducted a postflt inspection, picked up and reviewed the dispatch release, then took a bathroom break. After we returned to the aircraft, we completed the turnaround checklist and proceeded to wait for the passenger to board. We had not received a fuel slip on the earlier trip and we weren't too concerned that we had not received one on this trip. There was sufficient time from when I left the aircraft, went inside, and returned to the aircraft for a fuel truck to have come out to the plane and complete refueling. After boarding was completed, we had 3 mins left to make an on-time- departure. The flight attendant interrupted our before start checks to point out that the agent left the boarding rope attached to the aircraft. The ramp mechanic untied it and we started our checklist again, only this time we rushed to ensure the on-time departure. The fuel gauges were covered by the release paperwork. At this point, I feel that the current air carrier checklist fails in its purpose. There is no verification by both crew members concerning fuel, only a response from the first officer. While I was clearing the port side of the aircraft for engine start, the first officer was locking the door. When he stated the fuel level, the first officer used the planned fuel from the release. I had assumed he read the fuel from the gauges. From this point on, there is no further reference to the fuel in any checklist. Only when we leveled off at 14000 ft did either of us notice the fuel level. Contributing factors that I can identify include a level of complacency when both crew members have a high level of confidence in the other crew member to be able to perform their required duties, a series of events that include an interrupted checklist that distracts both crew members from the tasks at hand, a single point of failure in the checklist, ie, no required response from personnel concerning the fuel onboard, and a sense of urgency over ensuring an on-time departure. The single most effective corrective action I could recommend is a revision to the checklists currently in use to include a duel verification of the fuel on board at least twice before takeoff, once before start, and once during the taxi out. Supplemental information from acn 543792: the captain and I have met with the company and we suggest directions, rushing, and a weak checklist, along with complacency on our part, are to blame for the minimum fuel situation. Our company is in the process of changing our checklist from the first officer stating fuel on board to both crew members stating fuel on board. The captain and I have also received CRM and checklist training. Due to the unpleasant situation we put ourselves in, along with CRM training, we are confident this will not be a repeat occurrence.
Original NASA ASRS Text
Title: JETSTREAM 4100 FLC DIVERTED TO ANOTHER ARPT ENRTE AFTER DISCOVERING INFLT THAT THEY HAD INSUFFICIENT FUEL TO MAKE THEIR SCHEDULED DEST.
Narrative: ON THE CLBOUT, WE DETERMINED THAT WE HAD INSUFFICIENT FUEL TO PROCEED TO IAD. WE ASSESSED THE SIT, NOTIFIED ATC THAT WE HAD MINIMUM FUEL ON BOARD AND REQUESTED A DIVERSION TO EWR. ATC GRANTED US CLRNC TO EWR, WHICH WAS VFR AT THE TIME, AND WE PROCEEDED TO LAND WITH A CLRNC FOR A VISUAL APCH. THE LNDG WAS UNEVENTFUL. WE TAXIED TO THE GATE, NOTIFIED DISPATCH AND WERE RERELEASED TO IAD. THE FLT FROM EWR TO IAD WAS NORMAL. THE FO AND I HAD FLOWN 1 ROUND TRIP TOGETHER PRIOR TO THIS FLT. WE RPTED FOR DUTY AT XA00 AND A SUFFICIENT REST PERIOD. THE FIRST TRIP WAS ALSO A ROUND TRIP. DURING THE TURNAROUND, OPS PROCEEDED NORMALLY. WE ASKED FOR RAMP SVC, CONDUCTED A POSTFLT INSPECTION, PICKED UP AND REVIEWED THE DISPATCH RELEASE, THEN TOOK A BATHROOM BREAK. AFTER WE RETURNED TO THE ACFT, WE COMPLETED THE TURNAROUND CHKLIST AND PROCEEDED TO WAIT FOR THE PAX TO BOARD. WE HAD NOT RECEIVED A FUEL SLIP ON THE EARLIER TRIP AND WE WEREN'T TOO CONCERNED THAT WE HAD NOT RECEIVED ONE ON THIS TRIP. THERE WAS SUFFICIENT TIME FROM WHEN I LEFT THE ACFT, WENT INSIDE, AND RETURNED TO THE ACFT FOR A FUEL TRUCK TO HAVE COME OUT TO THE PLANE AND COMPLETE REFUELING. AFTER BOARDING WAS COMPLETED, WE HAD 3 MINS LEFT TO MAKE AN ON-TIME- DEP. THE FLT ATTENDANT INTERRUPTED OUR BEFORE START CHKS TO POINT OUT THAT THE AGENT LEFT THE BOARDING ROPE ATTACHED TO THE ACFT. THE RAMP MECH UNTIED IT AND WE STARTED OUR CHKLIST AGAIN, ONLY THIS TIME WE RUSHED TO ENSURE THE ON-TIME DEP. THE FUEL GAUGES WERE COVERED BY THE RELEASE PAPERWORK. AT THIS POINT, I FEEL THAT THE CURRENT ACR CHKLIST FAILS IN ITS PURPOSE. THERE IS NO VERIFICATION BY BOTH CREW MEMBERS CONCERNING FUEL, ONLY A RESPONSE FROM THE FO. WHILE I WAS CLRING THE PORT SIDE OF THE ACFT FOR ENG START, THE FO WAS LOCKING THE DOOR. WHEN HE STATED THE FUEL LEVEL, THE FO USED THE PLANNED FUEL FROM THE RELEASE. I HAD ASSUMED HE READ THE FUEL FROM THE GAUGES. FROM THIS POINT ON, THERE IS NO FURTHER REF TO THE FUEL IN ANY CHKLIST. ONLY WHEN WE LEVELED OFF AT 14000 FT DID EITHER OF US NOTICE THE FUEL LEVEL. CONTRIBUTING FACTORS THAT I CAN IDENT INCLUDE A LEVEL OF COMPLACENCY WHEN BOTH CREW MEMBERS HAVE A HIGH LEVEL OF CONFIDENCE IN THE OTHER CREW MEMBER TO BE ABLE TO PERFORM THEIR REQUIRED DUTIES, A SERIES OF EVENTS THAT INCLUDE AN INTERRUPTED CHKLIST THAT DISTRACTS BOTH CREW MEMBERS FROM THE TASKS AT HAND, A SINGLE POINT OF FAILURE IN THE CHKLIST, IE, NO REQUIRED RESPONSE FROM PERSONNEL CONCERNING THE FUEL ONBOARD, AND A SENSE OF URGENCY OVER ENSURING AN ON-TIME DEP. THE SINGLE MOST EFFECTIVE CORRECTIVE ACTION I COULD RECOMMEND IS A REVISION TO THE CHKLISTS CURRENTLY IN USE TO INCLUDE A DUEL VERIFICATION OF THE FUEL ON BOARD AT LEAST TWICE BEFORE TKOF, ONCE BEFORE START, AND ONCE DURING THE TAXI OUT. SUPPLEMENTAL INFO FROM ACN 543792: THE CAPT AND I HAVE MET WITH THE COMPANY AND WE SUGGEST DIRECTIONS, RUSHING, AND A WEAK CHKLIST, ALONG WITH COMPLACENCY ON OUR PART, ARE TO BLAME FOR THE MINIMUM FUEL SIT. OUR COMPANY IS IN THE PROCESS OF CHANGING OUR CHKLIST FROM THE FO STATING FUEL ON BOARD TO BOTH CREW MEMBERS STATING FUEL ON BOARD. THE CAPT AND I HAVE ALSO RECEIVED CRM AND CHKLIST TRAINING. DUE TO THE UNPLEASANT SIT WE PUT OURSELVES IN, ALONG WITH CRM TRAINING, WE ARE CONFIDENT THIS WILL NOT BE A REPEAT OCCURRENCE.
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.