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Attributes | |
ACN | 593833 |
Time | |
Date | 200309 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : stl.airport |
State Reference | MO |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Super 80 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 593833 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : far |
Independent Detector | aircraft equipment other aircraft equipment : fuel quantity indicator other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Inadvertent fuel imbal. Shortly before descent we noted right main fuel quantity indicating 900 pounds. Suspecting quantity indicator problem we switched to 'a' channel. After an initial, 9999, indication, a channel indicated 800 pounds. We pulled the books to research and shortly thereafter first officer noticed fuel xfeed lever in the open position. We had made a gate connection across stl terminal with less than an hour to an aircraft requiring an initial preflight. It is part of my first officer's habit pattern to check the fuel xfeed closed, and I believed I had established a similar habit of checking it during the before start checklist. Both of us recalled me stating the release fuel and xfeed closed, when we came to that item on the checklist. Yet somehow 2 highly experienced pilots missed it, and then failed to detect the error, despite normal in-flight time/fuel logging procedures, until the right quantity indicator dropped below the usual 4 digits. After conferring with the maintenance controller we elected to continue to a scheduled landing at fll. An uneventful flaps 28 degree landing was accomplished, aircraft control was good at all speeds, configns using 4-5 units of right aileron/rudder trim. The lesson learned: attention to detail is essential. You cannot double-check yourself enough even on the most after engine shutdown at fll. A check of main tank fuel operating normally.
Original NASA ASRS Text
Title: MD80 CREW LEFT THE FUEL XFEED VALVE OPEN ON THE PREFLT OF THE COCKPIT. THEY DID NOT NOTICE THE PROB UNTIL THE R FUEL TANK HAD APPROX 900 LBS.
Narrative: INADVERTENT FUEL IMBAL. SHORTLY BEFORE DSCNT WE NOTED R MAIN FUEL QUANTITY INDICATING 900 LBS. SUSPECTING QUANTITY INDICATOR PROB WE SWITCHED TO 'A' CHANNEL. AFTER AN INITIAL, 9999, INDICATION, A CHANNEL INDICATED 800 LBS. WE PULLED THE BOOKS TO RESEARCH AND SHORTLY THEREAFTER FO NOTICED FUEL XFEED LEVER IN THE OPEN POS. WE HAD MADE A GATE CONNECTION ACROSS STL TERMINAL WITH LESS THAN AN HR TO AN ACFT REQUIRING AN INITIAL PREFLT. IT IS PART OF MY FO'S HABIT PATTERN TO CHK THE FUEL XFEED CLOSED, AND I BELIEVED I HAD ESTABLISHED A SIMILAR HABIT OF CHKING IT DURING THE BEFORE START CHKLIST. BOTH OF US RECALLED ME STATING THE RELEASE FUEL AND XFEED CLOSED, WHEN WE CAME TO THAT ITEM ON THE CHKLIST. YET SOMEHOW 2 HIGHLY EXPERIENCED PLTS MISSED IT, AND THEN FAILED TO DETECT THE ERROR, DESPITE NORMAL INFLT TIME/FUEL LOGGING PROCS, UNTIL THE RIGHT QUANTITY INDICATOR DROPPED BELOW THE USUAL 4 DIGITS. AFTER CONFERRING WITH THE MAINT CTLR WE ELECTED TO CONTINUE TO A SCHEDULED LNDG AT FLL. AN UNEVENTFUL FLAPS 28 DEG LNDG WAS ACCOMPLISHED, ACFT CTL WAS GOOD AT ALL SPDS, CONFIGNS USING 4-5 UNITS OF R AILERON/RUDDER TRIM. THE LESSON LEARNED: ATTN TO DETAIL IS ESSENTIAL. YOU CANNOT DOUBLE-CHK YOURSELF ENOUGH EVEN ON THE MOST AFTER ENG SHUTDOWN AT FLL. A CHK OF MAIN TANK FUEL OPERATING NORMALLY.
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.