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|
Attributes | |
ACN | 656088 |
Time | |
Date | 200504 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | general aviation : corporate |
Make Model Name | Citation Excel |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : intermediate altitude descent : approach |
Route In Use | arrival star : zzz |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 78 flight time total : 6940 flight time type : 1334 |
ASRS Report | 656088 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 125 flight time total : 12933 flight time type : 179 |
ASRS Report | 656172 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure non adherence : far other anomaly other other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : low fuel lights |
Resolutory Action | flight crew : declared emergency flight crew : diverted to another airport flight crew : landed in emergency condition |
Supplementary | |
Problem Areas | Flight Crew Human Performance FAA Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
On a ferry flight from ZZZ1 to ZZZ2. At ZZZ1 FBO; fuel load was requested to bring total on board to 4000 pounds. Signed fuel receipt paying for fuel. Crew was under time constraints to make or meet schedule. PIC missed fuel quantity check on the before takeoff checklist. Departed VFR with busy local traffic; received IFR clearance in flight. On descent into ZZZ2 on arrival; fuel low level lights illuminated; alerting crew to 800 pounds remaining onboard. Fuel discrepancy was realized. Crew declared emergency and diverted to ZZZ3. The emergency checklist was executed and the flight landed without further assistance at ZZZ3. I believe this problem was caused for a number of reasons. First was crew fatigue. This was day seven of a seven day trip. Total duty up until this point was 73 hours out of a possible 84 hours. This trip sequence had some very long days with a very short rest time. As little as 10 hours on two of the days. Second cause was position of fuel quantity check on the checklist. This should be placed on the before start checklist. Before the aircraft is moving. Giving both pilots a chance to verify fuel onboard. Third cause was demands to make schedule with perceived repercussions by the crew from the company. Early in the week; the crew was questioned by the company for a one minute delay. Pilots being disciplined for failure to meet schedule. Supplemental information from acn 656172: the following table reflects start time and duty times for the tour. 4/sun/05; xa:00-xi:12; 9 hours 12 mins. 4/mon/05; xz:00-xl:00; 13 hours. 4/tue/05; xy:00-xl:00; 14 hours. 4/wed/05; xe:00-X3:06; 10 hours; 6 mins. 4/thu/05; xx:00-xt:34; 12 hours; 34 mins. 4/fri/05; xw:00-xh:54; 12 hours 54 mins. 4/sat/05; xy:54. This happened on the 7TH day of early duty starts on my biological clock and fatigue was a factor. We had a problem with the fuel bill and had to get it re-done. When we got to the aircraft; we were distracted by an inability to contact ATC for our clearance. Being in a hurry; I misread the fuel gauges. We were also pre-occupied with discussing how to safely get our clearance airborne. Although our duty times fell within legal limits; the long days and early starts contributed to fatigue. I let this cloud my judgement and I violated my own number one rule of safety; 'do not rush.'
Original NASA ASRS Text
Title: A CE560 FRACTIONAL CREW REPORTED FATIGUE AS A FACTOR IN THEIR OVERSIGHT OF DEP FUEL REQUIREMENTS. FLT CREW DEPARTED WITHOUT SUFFICIENT FUEL; DECLARED AN EMER AND DIVERTED SHORT OF THEIR DEST.
Narrative: ON A FERRY FLT FROM ZZZ1 TO ZZZ2. AT ZZZ1 FBO; FUEL LOAD WAS REQUESTED TO BRING TOTAL ON BOARD TO 4000 LBS. SIGNED FUEL RECEIPT PAYING FOR FUEL. CREW WAS UNDER TIME CONSTRAINTS TO MAKE OR MEET SCHEDULE. PIC MISSED FUEL QUANTITY CHECK ON THE BEFORE TKOF CHKLIST. DEPARTED VFR WITH BUSY LOCAL TFC; RECEIVED IFR CLRNC IN FLT. ON DSCNT INTO ZZZ2 ON ARR; FUEL LOW LEVEL LIGHTS ILLUMINATED; ALERTING CREW TO 800 LBS REMAINING ONBOARD. FUEL DISCREPANCY WAS REALIZED. CREW DECLARED EMER AND DIVERTED TO ZZZ3. THE EMER CHKLIST WAS EXECUTED AND THE FLT LANDED WITHOUT FURTHER ASSISTANCE AT ZZZ3. I BELIEVE THIS PROB WAS CAUSED FOR A NUMBER OF REASONS. FIRST WAS CREW FATIGUE. THIS WAS DAY SEVEN OF A SEVEN DAY TRIP. TOTAL DUTY UP UNTIL THIS POINT WAS 73 HOURS OUT OF A POSSIBLE 84 HOURS. THIS TRIP SEQUENCE HAD SOME VERY LONG DAYS WITH A VERY SHORT REST TIME. AS LITTLE AS 10 HOURS ON TWO OF THE DAYS. SECOND CAUSE WAS POSITION OF FUEL QUANTITY CHECK ON THE CHKLIST. THIS SHOULD BE PLACED ON THE BEFORE START CHKLIST. BEFORE THE ACFT IS MOVING. GIVING BOTH PLTS A CHANCE TO VERIFY FUEL ONBOARD. THIRD CAUSE WAS DEMANDS TO MAKE SCHEDULE WITH PERCEIVED REPERCUSSIONS BY THE CREW FROM THE COMPANY. EARLY IN THE WEEK; THE CREW WAS QUESTIONED BY THE COMPANY FOR A ONE MINUTE DELAY. PLTS BEING DISCIPLINED FOR FAILURE TO MEET SCHEDULE. SUPPLEMENTAL INFO FROM ACN 656172: THE FOLLOWING TABLE REFLECTS START TIME AND DUTY TIMES FOR THE TOUR. 4/SUN/05; XA:00-XI:12; 9 HOURS 12 MINS. 4/MON/05; XZ:00-XL:00; 13 HOURS. 4/TUE/05; XY:00-XL:00; 14 HOURS. 4/WED/05; XE:00-X3:06; 10 HOURS; 6 MINS. 4/THU/05; XX:00-XT:34; 12 HOURS; 34 MINS. 4/FRI/05; XW:00-XH:54; 12 HOURS 54 MINS. 4/SAT/05; XY:54. THIS HAPPENED ON THE 7TH DAY OF EARLY DUTY STARTS ON MY BIOLOGICAL CLOCK AND FATIGUE WAS A FACTOR. WE HAD A PROB WITH THE FUEL BILL AND HAD TO GET IT RE-DONE. WHEN WE GOT TO THE ACFT; WE WERE DISTRACTED BY AN INABILITY TO CONTACT ATC FOR OUR CLRNC. BEING IN A HURRY; I MISREAD THE FUEL GAUGES. WE WERE ALSO PRE-OCCUPIED WITH DISCUSSING HOW TO SAFELY GET OUR CLRNC AIRBORNE. ALTHOUGH OUR DUTY TIMES FELL WITHIN LEGAL LIMITS; THE LONG DAYS AND EARLY STARTS CONTRIBUTED TO FATIGUE. I LET THIS CLOUD MY JUDGEMENT AND I VIOLATED MY OWN NUMBER ONE RULE OF SAFETY; 'DO NOT RUSH.'
Data retrieved from NASA's ASRS site as of January 2009 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.