37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 572659 |
Time | |
Date | 200301 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : swf.airport |
State Reference | NY |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog Rain |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : maintenance ground : parked ground : preflight ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 90 flight time total : 8500 flight time type : 4500 |
ASRS Report | 572659 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer pilot : atp pilot : multi engine |
Experience | flight time total : 7500 |
ASRS Report | 573005 |
Events | |
Anomaly | maintenance problem : improper maintenance maintenance problem : improper documentation non adherence : far non adherence : company policies other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Supplementary | |
Problem Areas | Maintenance Human Performance Aircraft Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Scheduled departure at XA03 on jan/fri/03 was first delayed because of fuel flow controller problems. Aircraft had pushed back at XA27 after deicing, but returned to gate to have the fuel flow controller replaced. Aircraft pushed back the second time at XB40, taxied to runway 27 at swf, but had to return to the gate because the APU would not indicate a proper shutdown. After returning to the gate and having the APU deferred in accordance with the B727 MEL, the crew pushed back for the third time at XC47. During these episodes, 3 different weight and balance sheets were delivered to the crew to account for fuel burned. Just prior to pushback the third time, and as the last weight and balance sheet was being delivered, a new flight release was delivered and signed. During this last episode, although a new alternate of lit versus nqa was noted by the crew, it was not noted that required fuel increased from 33720 pounds to 36090 pounds. The crew continued to ensure that brake release fuel of 33720 pounds was on board and, in fact, released brakes with 34000 pounds. After takeoff, the error was noted and the crew evaluated options and elected to continue to mem on a direct routing to minimize fuel consumption. Additionally, the route was flown 2000 ft higher in order to further conserve fuel. As a result, the crew landed with 13600 pounds versus the 16400 ft indicated on the new release and would have landed at lit with 8600 pounds versus the 11400 pounds indicated on the new flight plan. Factors such as arrival WX at mem were considered well ahead of arrival so that diversion for extra fuel could have been executed. WX was checked with FSS. This problem was caused by the multiple returns to the gate, multiple weight and balance computations and the delivery of a new flight plan just moments before final pushback. A direct communication with the crew prior to final pushback could have prevented this error. Supplemental information from acn 537005: the problem was caused by delivery of a new flight plan just mins before pushback after 2 mechanicals, 2 returns to gate, 5 weight and balances. Normally, the ramp agent knows the required fuel and verbalizes this. Direct communications with the crew, CRM amongst all (crew and ramp) prior to push could have prevented this error. Being close on the original fuel required gained the attention that should have been spent amongst the new release.
Original NASA ASRS Text
Title: A B727 CARGO FLT SUFFERS MULTIPLE MECHANICALS AND RETURNS TO THE GATE, FINALLY DEPARTS BUT WITH LESS FUEL THAN STIPULATED ON THE NEW DISPATCH RELEASE ISSUED ON THIRD PUSHBACK AT SWF, NY.
Narrative: SCHEDULED DEP AT XA03 ON JAN/FRI/03 WAS FIRST DELAYED BECAUSE OF FUEL FLOW CONTROLLER PROBS. ACFT HAD PUSHED BACK AT XA27 AFTER DEICING, BUT RETURNED TO GATE TO HAVE THE FUEL FLOW CONTROLLER REPLACED. ACFT PUSHED BACK THE SECOND TIME AT XB40, TAXIED TO RWY 27 AT SWF, BUT HAD TO RETURN TO THE GATE BECAUSE THE APU WOULD NOT INDICATE A PROPER SHUTDOWN. AFTER RETURNING TO THE GATE AND HAVING THE APU DEFERRED IN ACCORDANCE WITH THE B727 MEL, THE CREW PUSHED BACK FOR THE THIRD TIME AT XC47. DURING THESE EPISODES, 3 DIFFERENT WT AND BAL SHEETS WERE DELIVERED TO THE CREW TO ACCOUNT FOR FUEL BURNED. JUST PRIOR TO PUSHBACK THE THIRD TIME, AND AS THE LAST WT AND BAL SHEET WAS BEING DELIVERED, A NEW FLT RELEASE WAS DELIVERED AND SIGNED. DURING THIS LAST EPISODE, ALTHOUGH A NEW ALTERNATE OF LIT VERSUS NQA WAS NOTED BY THE CREW, IT WAS NOT NOTED THAT REQUIRED FUEL INCREASED FROM 33720 LBS TO 36090 LBS. THE CREW CONTINUED TO ENSURE THAT BRAKE RELEASE FUEL OF 33720 LBS WAS ON BOARD AND, IN FACT, RELEASED BRAKES WITH 34000 LBS. AFTER TKOF, THE ERROR WAS NOTED AND THE CREW EVALUATED OPTIONS AND ELECTED TO CONTINUE TO MEM ON A DIRECT ROUTING TO MINIMIZE FUEL CONSUMPTION. ADDITIONALLY, THE RTE WAS FLOWN 2000 FT HIGHER IN ORDER TO FURTHER CONSERVE FUEL. AS A RESULT, THE CREW LANDED WITH 13600 LBS VERSUS THE 16400 FT INDICATED ON THE NEW RELEASE AND WOULD HAVE LANDED AT LIT WITH 8600 LBS VERSUS THE 11400 LBS INDICATED ON THE NEW FLT PLAN. FACTORS SUCH AS ARR WX AT MEM WERE CONSIDERED WELL AHEAD OF ARR SO THAT DIVERSION FOR EXTRA FUEL COULD HAVE BEEN EXECUTED. WX WAS CHKED WITH FSS. THIS PROB WAS CAUSED BY THE MULTIPLE RETURNS TO THE GATE, MULTIPLE WT AND BAL COMPUTATIONS AND THE DELIVERY OF A NEW FLT PLAN JUST MOMENTS BEFORE FINAL PUSHBACK. A DIRECT COM WITH THE CREW PRIOR TO FINAL PUSHBACK COULD HAVE PREVENTED THIS ERROR. SUPPLEMENTAL INFO FROM ACN 537005: THE PROB WAS CAUSED BY DELIVERY OF A NEW FLT PLAN JUST MINS BEFORE PUSHBACK AFTER 2 MECHANICALS, 2 RETURNS TO GATE, 5 WT AND BALS. NORMALLY, THE RAMP AGENT KNOWS THE REQUIRED FUEL AND VERBALIZES THIS. DIRECT COMS WITH THE CREW, CRM AMONGST ALL (CREW AND RAMP) PRIOR TO PUSH COULD HAVE PREVENTED THIS ERROR. BEING CLOSE ON THE ORIGINAL FUEL REQUIRED GAINED THE ATTN THAT SHOULD HAVE BEEN SPENT AMONGST THE NEW RELEASE.
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.