Narrative:

It was determined on the ground in burbank that the #2 fuel gauge was not indicating correctly; causing the gauge to be MEL'ed and precipitating a 2 1/2 hour delay. Upon arrival in seattle while conducting a CAT III autoland approach; received an approach warning (on GS and localizer -- I believe the approach warning was due to aircraft slowing about 3-4 KTS below target speed); so elected to go around. On the second CAT III approach; ATC turned us in tight. We were on localizer and a little less than 1 DOT high; using vertical speed to capture the GS. The autoplt captured the altitude that was set in the altitude window; causing us to go high on the GS; so again elected to go around; and go to yakima; which was one of our alternates. We advised ATC en route of minimum fuel; and landed in yakima with 2300 pounds; based on total fuel burn subtracted from our departure fuel. This was significantly less than what I had calculated we would land with; due in part to ATC keeping us down while departing the sea area and vectors. It was a poor decision on my part not to proceed immediately to yakima after the first approach; and is a situation I won't allow to occur again. One big contributing factor was fatigue. When we arrived in yakima we could not fly the plane back to seattle because we were out of duty time. Being used to flying early morning trips; and having gotten up early in the day; I believe I experienced sort of a 'gradual' loss of judgement rather than a sudden loss of judgement; just due to being tired after the long day. In the future: 1) I will treat total fuel quantity calculations with much more skepticism when an inoperative fuel gauge is involved. Relying on a single gauge can introduce unanticipated errors that may or may not be detected. 2) I will assume I've got 1000 pounds less fuel than what I've calculated I've got. If you do a quick rough calculation of total fuel on board by doubling the quantity in the operative gauge's tank; and that gauge is reading higher than it should due to attitude or normal variance; you double the error. 3) I will be more cognizant of my own state of fatigue; and adjust my own personal minimums accordingly. Had I evaluated myself; I would have likely realized I was becoming fatigued. I speculate that my fuel calculation was skewed because of fatigue more than the operative gauge indicating too high; etc. I suspect I miscalculated how much fuel we would have remaining if we missed on our second approach; and based my decision to do a second approach on that miscalculation. On a more positive note; I believe we made the right decision in diverting to yakima. It would have been much simpler to come around and shoot another CAT III and let the jet land itself in seattle. But we both felt that going to yakima was the best plan. While we landed with a lot less fuel; and more 'paperwork;' we knew we would get in by going to yakima. Supplemental information from acn 678552: we checked the WX in seattle and it was 1000 ft RVR; 1/4 mi; 100 ft overcast. We changed pilot duties and the captain was now the PF for preparation for a CAT III into seattle. We wrote up my map light and sent an ACARS to sea maintenance. During the flight we manually calculated our fuel by subtracting the fuel used from our estimated takeoff fuel quantity. When prompted by the FMC; we would manually input the fuel in the proper line. Both gauges were not agreeing with our figures. We briefed the proper items for a CAT III autoland and were lined up in the sequence with the other aircraft for sea ILS runway 16R III. The line-up was very long and we were slowed considerably for an extended period of time; resulting in flap extension and fuel consumption. During the CAT III autoland approach we received an approach warning at approximately 300 ft above minimums. Following standard protocol; we initiated an uneventful missed approach. ATC took us around for a second approach very quickly and this is where the problems escalated. ATC brought us on the approach approximately 2 mi north. Consequently; the captain dealing with a certain amount of fatigue and being rattled by the irregularitiesof the missed approach intercepted the localizer at 2100 ft AGL with the altitude hold selected and approach armed. The only problem was we were put on the localizer slightly above the GS. The captain hand flew the second missed approach. The captain was now dealing with fatigue and I suspect a little bit of vertigo on the second missed approach. My performance was also suffering with fatigue and the frustration trying to do my duties in the dark because of my inoperative map light. We called dispatch; notified them of our fuel; and were instructed to divert immediately to ykm. With our instructions; we proceeded to ykm. En route to ykm; we did another manual calculation of the fuel and realized that making that second approach was a big mistake. The most troubling issue other than fatigue; frustration; WX and my burnt out map light was that both fuel quantity indicators were not reading what we thought they should read. The manual calculations were all we had to go on. As a precaution we declared minimum fuel with ATC for priority handling with no delays. I feel the issues surrounding the problems related with this flight include improper planning resulting from the MEL of the fuel quantity indicator and the WX in seattle. I think if the fuel quantity indicator was working correctly; we may have looked to see how much fuel we had prior to initiating that second approach. It was our oversight and our mistake. 1) we should have briefed a plan for the number of approachs we could do into seattle and a hard bingo number. 2) we should not have let ATC rush us on that second approach which directly resulted in us getting behind on the second approach; exceeding the stabilized approach parameters trying to catch up; and ultimately a second missed approach. 3) we needed to pay better attention to our fuel situation; especially taking into consideration of the MEL and the WX in seattle. 4) I need to better address fatigue as major considerations for myself as well and verbalize to my partner that I am feeling tired and we need to take things a little slower and methodically when we're starting to get rushed.

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Original NASA ASRS Text

Title: FOLLOWING 2 MISSED APCHS A FATIGUED B737-400 CREW WITH INOP FUEL GAUGES DIVERTS TO AN ALTERNATE BECAUSE THEY DOUBT THE ACTUAL FUEL QUANTITY ON BOARD.

Narrative: IT WAS DETERMINED ON THE GND IN BURBANK THAT THE #2 FUEL GAUGE WAS NOT INDICATING CORRECTLY; CAUSING THE GAUGE TO BE MEL'ED AND PRECIPITATING A 2 1/2 HR DELAY. UPON ARR IN SEATTLE WHILE CONDUCTING A CAT III AUTOLAND APCH; RECEIVED AN APCH WARNING (ON GS AND LOC -- I BELIEVE THE APCH WARNING WAS DUE TO ACFT SLOWING ABOUT 3-4 KTS BELOW TARGET SPD); SO ELECTED TO GO AROUND. ON THE SECOND CAT III APCH; ATC TURNED US IN TIGHT. WE WERE ON LOC AND A LITTLE LESS THAN 1 DOT HIGH; USING VERT SPD TO CAPTURE THE GS. THE AUTOPLT CAPTURED THE ALT THAT WAS SET IN THE ALT WINDOW; CAUSING US TO GO HIGH ON THE GS; SO AGAIN ELECTED TO GO AROUND; AND GO TO YAKIMA; WHICH WAS ONE OF OUR ALTERNATES. WE ADVISED ATC ENRTE OF MINIMUM FUEL; AND LANDED IN YAKIMA WITH 2300 LBS; BASED ON TOTAL FUEL BURN SUBTRACTED FROM OUR DEP FUEL. THIS WAS SIGNIFICANTLY LESS THAN WHAT I HAD CALCULATED WE WOULD LAND WITH; DUE IN PART TO ATC KEEPING US DOWN WHILE DEPARTING THE SEA AREA AND VECTORS. IT WAS A POOR DECISION ON MY PART NOT TO PROCEED IMMEDIATELY TO YAKIMA AFTER THE FIRST APCH; AND IS A SITUATION I WON'T ALLOW TO OCCUR AGAIN. ONE BIG CONTRIBUTING FACTOR WAS FATIGUE. WHEN WE ARRIVED IN YAKIMA WE COULD NOT FLY THE PLANE BACK TO SEATTLE BECAUSE WE WERE OUT OF DUTY TIME. BEING USED TO FLYING EARLY MORNING TRIPS; AND HAVING GOTTEN UP EARLY IN THE DAY; I BELIEVE I EXPERIENCED SORT OF A 'GRADUAL' LOSS OF JUDGEMENT RATHER THAN A SUDDEN LOSS OF JUDGEMENT; JUST DUE TO BEING TIRED AFTER THE LONG DAY. IN THE FUTURE: 1) I WILL TREAT TOTAL FUEL QUANTITY CALCULATIONS WITH MUCH MORE SKEPTICISM WHEN AN INOP FUEL GAUGE IS INVOLVED. RELYING ON A SINGLE GAUGE CAN INTRODUCE UNANTICIPATED ERRORS THAT MAY OR MAY NOT BE DETECTED. 2) I WILL ASSUME I'VE GOT 1000 LBS LESS FUEL THAN WHAT I'VE CALCULATED I'VE GOT. IF YOU DO A QUICK ROUGH CALCULATION OF TOTAL FUEL ON BOARD BY DOUBLING THE QUANTITY IN THE OPERATIVE GAUGE'S TANK; AND THAT GAUGE IS READING HIGHER THAN IT SHOULD DUE TO ATTITUDE OR NORMAL VARIANCE; YOU DOUBLE THE ERROR. 3) I WILL BE MORE COGNIZANT OF MY OWN STATE OF FATIGUE; AND ADJUST MY OWN PERSONAL MINIMUMS ACCORDINGLY. HAD I EVALUATED MYSELF; I WOULD HAVE LIKELY REALIZED I WAS BECOMING FATIGUED. I SPECULATE THAT MY FUEL CALCULATION WAS SKEWED BECAUSE OF FATIGUE MORE THAN THE OPERATIVE GAUGE INDICATING TOO HIGH; ETC. I SUSPECT I MISCALCULATED HOW MUCH FUEL WE WOULD HAVE REMAINING IF WE MISSED ON OUR SECOND APCH; AND BASED MY DECISION TO DO A SECOND APCH ON THAT MISCALCULATION. ON A MORE POSITIVE NOTE; I BELIEVE WE MADE THE RIGHT DECISION IN DIVERTING TO YAKIMA. IT WOULD HAVE BEEN MUCH SIMPLER TO COME AROUND AND SHOOT ANOTHER CAT III AND LET THE JET LAND ITSELF IN SEATTLE. BUT WE BOTH FELT THAT GOING TO YAKIMA WAS THE BEST PLAN. WHILE WE LANDED WITH A LOT LESS FUEL; AND MORE 'PAPERWORK;' WE KNEW WE WOULD GET IN BY GOING TO YAKIMA. SUPPLEMENTAL INFO FROM ACN 678552: WE CHKED THE WX IN SEATTLE AND IT WAS 1000 FT RVR; 1/4 MI; 100 FT OVCST. WE CHANGED PLT DUTIES AND THE CAPT WAS NOW THE PF FOR PREPARATION FOR A CAT III INTO SEATTLE. WE WROTE UP MY MAP LIGHT AND SENT AN ACARS TO SEA MAINT. DURING THE FLT WE MANUALLY CALCULATED OUR FUEL BY SUBTRACTING THE FUEL USED FROM OUR ESTIMATED TKOF FUEL QUANTITY. WHEN PROMPTED BY THE FMC; WE WOULD MANUALLY INPUT THE FUEL IN THE PROPER LINE. BOTH GAUGES WERE NOT AGREEING WITH OUR FIGURES. WE BRIEFED THE PROPER ITEMS FOR A CAT III AUTOLAND AND WERE LINED UP IN THE SEQUENCE WITH THE OTHER ACFT FOR SEA ILS RWY 16R III. THE LINE-UP WAS VERY LONG AND WE WERE SLOWED CONSIDERABLY FOR AN EXTENDED PERIOD OF TIME; RESULTING IN FLAP EXTENSION AND FUEL CONSUMPTION. DURING THE CAT III AUTOLAND APCH WE RECEIVED AN APCH WARNING AT APPROX 300 FT ABOVE MINIMUMS. FOLLOWING STANDARD PROTOCOL; WE INITIATED AN UNEVENTFUL MISSED APCH. ATC TOOK US AROUND FOR A SECOND APCH VERY QUICKLY AND THIS IS WHERE THE PROBS ESCALATED. ATC BROUGHT US ON THE APCH APPROX 2 MI N. CONSEQUENTLY; THE CAPT DEALING WITH A CERTAIN AMOUNT OF FATIGUE AND BEING RATTLED BY THE IRREGULARITIESOF THE MISSED APCH INTERCEPTED THE LOC AT 2100 FT AGL WITH THE ALT HOLD SELECTED AND APCH ARMED. THE ONLY PROB WAS WE WERE PUT ON THE LOC SLIGHTLY ABOVE THE GS. THE CAPT HAND FLEW THE SECOND MISSED APCH. THE CAPT WAS NOW DEALING WITH FATIGUE AND I SUSPECT A LITTLE BIT OF VERTIGO ON THE SECOND MISSED APCH. MY PERFORMANCE WAS ALSO SUFFERING WITH FATIGUE AND THE FRUSTRATION TRYING TO DO MY DUTIES IN THE DARK BECAUSE OF MY INOP MAP LIGHT. WE CALLED DISPATCH; NOTIFIED THEM OF OUR FUEL; AND WERE INSTRUCTED TO DIVERT IMMEDIATELY TO YKM. WITH OUR INSTRUCTIONS; WE PROCEEDED TO YKM. ENRTE TO YKM; WE DID ANOTHER MANUAL CALCULATION OF THE FUEL AND REALIZED THAT MAKING THAT SECOND APCH WAS A BIG MISTAKE. THE MOST TROUBLING ISSUE OTHER THAN FATIGUE; FRUSTRATION; WX AND MY BURNT OUT MAP LIGHT WAS THAT BOTH FUEL QUANTITY INDICATORS WERE NOT READING WHAT WE THOUGHT THEY SHOULD READ. THE MANUAL CALCULATIONS WERE ALL WE HAD TO GO ON. AS A PRECAUTION WE DECLARED MINIMUM FUEL WITH ATC FOR PRIORITY HANDLING WITH NO DELAYS. I FEEL THE ISSUES SURROUNDING THE PROBS RELATED WITH THIS FLT INCLUDE IMPROPER PLANNING RESULTING FROM THE MEL OF THE FUEL QUANTITY INDICATOR AND THE WX IN SEATTLE. I THINK IF THE FUEL QUANTITY INDICATOR WAS WORKING CORRECTLY; WE MAY HAVE LOOKED TO SEE HOW MUCH FUEL WE HAD PRIOR TO INITIATING THAT SECOND APCH. IT WAS OUR OVERSIGHT AND OUR MISTAKE. 1) WE SHOULD HAVE BRIEFED A PLAN FOR THE NUMBER OF APCHS WE COULD DO INTO SEATTLE AND A HARD BINGO NUMBER. 2) WE SHOULD NOT HAVE LET ATC RUSH US ON THAT SECOND APCH WHICH DIRECTLY RESULTED IN US GETTING BEHIND ON THE SECOND APCH; EXCEEDING THE STABILIZED APCH PARAMETERS TRYING TO CATCH UP; AND ULTIMATELY A SECOND MISSED APCH. 3) WE NEEDED TO PAY BETTER ATTN TO OUR FUEL SITUATION; ESPECIALLY TAKING INTO CONSIDERATION OF THE MEL AND THE WX IN SEATTLE. 4) I NEED TO BETTER ADDRESS FATIGUE AS MAJOR CONSIDERATIONS FOR MYSELF AS WELL AND VERBALIZE TO MY PARTNER THAT I AM FEELING TIRED AND WE NEED TO TAKE THINGS A LITTLE SLOWER AND METHODICALLY WHEN WE'RE STARTING TO GET RUSHED.

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.