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|
Attributes | |
ACN | 782909 |
Time | |
Date | 200804 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Aircraft 1 | |
Controlling Facilities | tracon : d10.tracon |
Operator | general aviation : corporate |
Make Model Name | Gates Learjet Corp Undifferentiated or Other Model |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : parked |
Person 1 | |
Affiliation | company : corporate |
Function | oversight : pic |
ASRS Report | 782909 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp |
ASRS Report | 782910 |
Events | |
Anomaly | aircraft equipment problem : less severe |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Upon landing; a postflt inspection was conducted after the passenger were deplaned. During the postflt; the line man called our attention to the rear of the aircraft and to the fuel door. The fuel door was open and the fuel cap was missing. We thoroughly inspected the aircraft for further damage. There was no damage to the aircraft at all. The door was not bent or damaged and functioned properly. We contacted the flight operations duty manager and maintenance as well as dispatch. In coordination with the fodm; we initiated an extensive search via telephone. The runways and txwys were searched as well as the ramp areas at the departure and arrival airports. The fuel cap was not located. Taking into consideration the weight of the cap; it is my feeling that the cap was most likely not reinstalled after fueling in lga and the tether chain was not attached to the aircraft. If the cap was left dangling it would have made quite a bit of noise and done considerable damage to the aircraft. There was not so much as a scratch on the fuselage of the aircraft. The event could have been avoided had I or my first officer checked the fuel door prior to departure. The event was quite simply the result of a classic error chain situation. We arrived at the FBO at XA25 for an XB30. My first officer proceeded directly to the aircraft and I went to the desk to get the paperwork. I then checked WX and was informed at approximately XB35 that our passenger had arrived. I called the first officer and informed him; asking how much time he needed. I then greeted the passenger and explained politely that we would need a few mins to get things ready but that we would have them underway as soon as possible. I then took their bags and proceeded to the aircraft after placing a fuel order at the desk. We hurried to get things ready and when we were close to prepared; I returned to the FBO. My first officer called to tell me he was ready -- with the exception of the catering which had not yet arrived at our airplane. I elected to bring the catering with me to the aircraft along with the passenger. We boarded the passenger. I unboxed the catering closed the door briefed the passenger and we were proceeded to start engines. In the rush induced by the passenger's early arrival; I neglected to rechk the fuel cap after fueling. Had I rechked the fuel cap or asked the first officer to do so; we could have avoided the initial error of the fueler and broke the error chain prior to any possible problems. I know better than this. It is my policy to verify the fuel cap security after every refueling event. 3 times since I have been with company; I have caught the fueler's error and re-secured the cap or the door during a post fueling event. I know this procedure well. I will never let anything rush me to the point of missing such an important item. I felt that by going to the aircraft and assisting my first officer; I could ease the pressure yet still be able to get the passenger off the ground as quickly as possible. I do feel we were paying sufficient attention to all safety of flight issues and felt at the time I returned for the passenger that everything was in order and sufficiently attended to. The last min catering dilemma distraction me just enough to allow me to forget that one important item. If perhaps the before start checklist began with fuel cap checked; it may prevent this problem in the future and help other crews to avoid this problem as the preflight inspection is often done before the fueler arrives and the fuel cap verification is a separate yet important procedure.
Original NASA ASRS Text
Title: LR40 FLT CREW DISCOVERS ON POST FLIGHT THAT THE SINGLE POINT REFUELING CAP IS MISSING AND THE ACCESS PANEL IS OPEN.
Narrative: UPON LNDG; A POSTFLT INSPECTION WAS CONDUCTED AFTER THE PAX WERE DEPLANED. DURING THE POSTFLT; THE LINE MAN CALLED OUR ATTN TO THE REAR OF THE ACFT AND TO THE FUEL DOOR. THE FUEL DOOR WAS OPEN AND THE FUEL CAP WAS MISSING. WE THOROUGHLY INSPECTED THE ACFT FOR FURTHER DAMAGE. THERE WAS NO DAMAGE TO THE ACFT AT ALL. THE DOOR WAS NOT BENT OR DAMAGED AND FUNCTIONED PROPERLY. WE CONTACTED THE FLT OPS DUTY MGR AND MAINT AS WELL AS DISPATCH. IN COORD WITH THE FODM; WE INITIATED AN EXTENSIVE SEARCH VIA TELEPHONE. THE RWYS AND TXWYS WERE SEARCHED AS WELL AS THE RAMP AREAS AT THE DEP AND ARR ARPTS. THE FUEL CAP WAS NOT LOCATED. TAKING INTO CONSIDERATION THE WT OF THE CAP; IT IS MY FEELING THAT THE CAP WAS MOST LIKELY NOT REINSTALLED AFTER FUELING IN LGA AND THE TETHER CHAIN WAS NOT ATTACHED TO THE ACFT. IF THE CAP WAS LEFT DANGLING IT WOULD HAVE MADE QUITE A BIT OF NOISE AND DONE CONSIDERABLE DAMAGE TO THE ACFT. THERE WAS NOT SO MUCH AS A SCRATCH ON THE FUSELAGE OF THE ACFT. THE EVENT COULD HAVE BEEN AVOIDED HAD I OR MY FO CHKED THE FUEL DOOR PRIOR TO DEP. THE EVENT WAS QUITE SIMPLY THE RESULT OF A CLASSIC ERROR CHAIN SIT. WE ARRIVED AT THE FBO AT XA25 FOR AN XB30. MY FO PROCEEDED DIRECTLY TO THE ACFT AND I WENT TO THE DESK TO GET THE PAPERWORK. I THEN CHKED WX AND WAS INFORMED AT APPROX XB35 THAT OUR PAX HAD ARRIVED. I CALLED THE FO AND INFORMED HIM; ASKING HOW MUCH TIME HE NEEDED. I THEN GREETED THE PAX AND EXPLAINED POLITELY THAT WE WOULD NEED A FEW MINS TO GET THINGS READY BUT THAT WE WOULD HAVE THEM UNDERWAY ASAP. I THEN TOOK THEIR BAGS AND PROCEEDED TO THE ACFT AFTER PLACING A FUEL ORDER AT THE DESK. WE HURRIED TO GET THINGS READY AND WHEN WE WERE CLOSE TO PREPARED; I RETURNED TO THE FBO. MY FO CALLED TO TELL ME HE WAS READY -- WITH THE EXCEPTION OF THE CATERING WHICH HAD NOT YET ARRIVED AT OUR AIRPLANE. I ELECTED TO BRING THE CATERING WITH ME TO THE ACFT ALONG WITH THE PAX. WE BOARDED THE PAX. I UNBOXED THE CATERING CLOSED THE DOOR BRIEFED THE PAX AND WE WERE PROCEEDED TO START ENGS. IN THE RUSH INDUCED BY THE PAX'S EARLY ARR; I NEGLECTED TO RECHK THE FUEL CAP AFTER FUELING. HAD I RECHKED THE FUEL CAP OR ASKED THE FO TO DO SO; WE COULD HAVE AVOIDED THE INITIAL ERROR OF THE FUELER AND BROKE THE ERROR CHAIN PRIOR TO ANY POSSIBLE PROBS. I KNOW BETTER THAN THIS. IT IS MY POLICY TO VERIFY THE FUEL CAP SECURITY AFTER EVERY REFUELING EVENT. 3 TIMES SINCE I HAVE BEEN WITH COMPANY; I HAVE CAUGHT THE FUELER'S ERROR AND RE-SECURED THE CAP OR THE DOOR DURING A POST FUELING EVENT. I KNOW THIS PROC WELL. I WILL NEVER LET ANYTHING RUSH ME TO THE POINT OF MISSING SUCH AN IMPORTANT ITEM. I FELT THAT BY GOING TO THE ACFT AND ASSISTING MY FO; I COULD EASE THE PRESSURE YET STILL BE ABLE TO GET THE PAX OFF THE GND AS QUICKLY AS POSSIBLE. I DO FEEL WE WERE PAYING SUFFICIENT ATTN TO ALL SAFETY OF FLT ISSUES AND FELT AT THE TIME I RETURNED FOR THE PAX THAT EVERYTHING WAS IN ORDER AND SUFFICIENTLY ATTENDED TO. THE LAST MIN CATERING DILEMMA DISTR ME JUST ENOUGH TO ALLOW ME TO FORGET THAT ONE IMPORTANT ITEM. IF PERHAPS THE BEFORE START CHKLIST BEGAN WITH FUEL CAP CHKED; IT MAY PREVENT THIS PROB IN THE FUTURE AND HELP OTHER CREWS TO AVOID THIS PROB AS THE PREFLT INSPECTION IS OFTEN DONE BEFORE THE FUELER ARRIVES AND THE FUEL CAP VERIFICATION IS A SEPARATE YET IMPORTANT PROC.
Data retrieved from NASA's ASRS site as of May 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.