37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 736467 |
Time | |
Date | 200704 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
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 |
ASRS Report | 736467 |
Events | |
Anomaly | non adherence : far non adherence : published procedure non adherence : company policies |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
After some discussion with my first officer we concluded that factors that may have contributed to the problem were routine distrs during loading. In addition; the aircraft had been swapped and the fueler probably thought that the correct fuel load had been put on. In addition; I believe that I saw what I wanted to see because the loaded number in the fuel tank looked like the required fuel from the previous flight. Finally we were distraction from doing our primary duty and failed to verify the fuel load as the checklist requires. At cruise altitude and roughly midway through the flight; I did my routine checks. It was then that my first officer and I discovered that we were missing fuel. After doing some quick calculations using performance manuals and distance remaining; we determined that we still had adequate fuel including reserves to continue to stl. As a precaution we reduced thrust and requested direct from ATC which was granted. The WX was clear for the remainder of the trip; but we got out maps to ensure that we had options in case anything unforeseen should occur. I then ran back through the load manifest with a revised estimate of our fuel load to determine if at any time we had been out of limits. I determined that we had not been out of center of gravity and had not exceeded any limitations but we had left the ground with less than minimum fuel. At no time after the discovery did we feel that the aircraft or passenger were in jeopardy. We continued the flight and landed without incident with 2000 pounds of fuel remaining. As a professional; I recognize that this situation was totally unacceptable and completely avoidable. As captain; it is my responsibility to check that we had adequate fuel for the trip and I failed to do so. Somehow; both my first officer and myself had failed to verify the correct fuel load before leaving the ground. During my routine checking of fuel burn; winds aloft; flight planned conditions; etc; I noticed a difference between the fuel remaining in the FMS and what actually remained in the tanks. The first officer verified this and we began immediately to determine our remaining fuel and that required to complete the trip. As a precaution we reduced our thrust and asked ATC for direct to stl. At this time we were approximately 45 mins away. Our first order of business was to ensure an adequate fuel state; which we did. Always verify what is on the release with what is on the aircraft; period. There was no excuse for this occurrence. Also; be aware that what you give the FMS is exactly what it will give you back. Verify your actual numbers all the time every time.
Original NASA ASRS Text
Title: EMB145 FLT CREW DEPARTS WITHOUT THE REQUIRED AMOUNT OF FUEL ONBOARD AFTER AN ACFT SWAP AND ROUTINE DISTRACTIONS.
Narrative: AFTER SOME DISCUSSION WITH MY FO WE CONCLUDED THAT FACTORS THAT MAY HAVE CONTRIBUTED TO THE PROB WERE ROUTINE DISTRS DURING LOADING. IN ADDITION; THE ACFT HAD BEEN SWAPPED AND THE FUELER PROBABLY THOUGHT THAT THE CORRECT FUEL LOAD HAD BEEN PUT ON. IN ADDITION; I BELIEVE THAT I SAW WHAT I WANTED TO SEE BECAUSE THE LOADED NUMBER IN THE FUEL TANK LOOKED LIKE THE REQUIRED FUEL FROM THE PREVIOUS FLT. FINALLY WE WERE DISTR FROM DOING OUR PRIMARY DUTY AND FAILED TO VERIFY THE FUEL LOAD AS THE CHKLIST REQUIRES. AT CRUISE ALT AND ROUGHLY MIDWAY THROUGH THE FLT; I DID MY ROUTINE CHKS. IT WAS THEN THAT MY FO AND I DISCOVERED THAT WE WERE MISSING FUEL. AFTER DOING SOME QUICK CALCULATIONS USING PERFORMANCE MANUALS AND DISTANCE REMAINING; WE DETERMINED THAT WE STILL HAD ADEQUATE FUEL INCLUDING RESERVES TO CONTINUE TO STL. AS A PRECAUTION WE REDUCED THRUST AND REQUESTED DIRECT FROM ATC WHICH WAS GRANTED. THE WX WAS CLR FOR THE REMAINDER OF THE TRIP; BUT WE GOT OUT MAPS TO ENSURE THAT WE HAD OPTIONS IN CASE ANYTHING UNFORESEEN SHOULD OCCUR. I THEN RAN BACK THROUGH THE LOAD MANIFEST WITH A REVISED ESTIMATE OF OUR FUEL LOAD TO DETERMINE IF AT ANY TIME WE HAD BEEN OUT OF LIMITS. I DETERMINED THAT WE HAD NOT BEEN OUT OF CTR OF GRAVITY AND HAD NOT EXCEEDED ANY LIMITATIONS BUT WE HAD LEFT THE GND WITH LESS THAN MINIMUM FUEL. AT NO TIME AFTER THE DISCOVERY DID WE FEEL THAT THE ACFT OR PAX WERE IN JEOPARDY. WE CONTINUED THE FLT AND LANDED WITHOUT INCIDENT WITH 2000 LBS OF FUEL REMAINING. AS A PROFESSIONAL; I RECOGNIZE THAT THIS SITUATION WAS TOTALLY UNACCEPTABLE AND COMPLETELY AVOIDABLE. AS CAPT; IT IS MY RESPONSIBILITY TO CHK THAT WE HAD ADEQUATE FUEL FOR THE TRIP AND I FAILED TO DO SO. SOMEHOW; BOTH MY FO AND MYSELF HAD FAILED TO VERIFY THE CORRECT FUEL LOAD BEFORE LEAVING THE GND. DURING MY ROUTINE CHKING OF FUEL BURN; WINDS ALOFT; FLT PLANNED CONDITIONS; ETC; I NOTICED A DIFFERENCE BTWN THE FUEL REMAINING IN THE FMS AND WHAT ACTUALLY REMAINED IN THE TANKS. THE FO VERIFIED THIS AND WE BEGAN IMMEDIATELY TO DETERMINE OUR REMAINING FUEL AND THAT REQUIRED TO COMPLETE THE TRIP. AS A PRECAUTION WE REDUCED OUR THRUST AND ASKED ATC FOR DIRECT TO STL. AT THIS TIME WE WERE APPROX 45 MINS AWAY. OUR FIRST ORDER OF BUSINESS WAS TO ENSURE AN ADEQUATE FUEL STATE; WHICH WE DID. ALWAYS VERIFY WHAT IS ON THE RELEASE WITH WHAT IS ON THE ACFT; PERIOD. THERE WAS NO EXCUSE FOR THIS OCCURRENCE. ALSO; BE AWARE THAT WHAT YOU GIVE THE FMS IS EXACTLY WHAT IT WILL GIVE YOU BACK. VERIFY YOUR ACTUAL NUMBERS ALL THE TIME EVERY TIME.
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.