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Fatigue induced by draconian scheduling practices contributes to a fuel imbalance anomaly.
| Attributes | |
| ACN | 814229 |
| Time | |
| Date | 200812 |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : pdx.airport |
| State Reference | OR |
| Altitude | agl single value : 0 |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | B757-200 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | ground : parked |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Experience | flight time last 90 days : 189 flight time total : 6500 flight time type : 393 |
| ASRS Report | 814229 |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : published procedure other anomaly other |
| Independent Detector | aircraft equipment other aircraft equipment : fuel config eicas msg |
| Resolutory Action | flight crew : overcame equipment problem |
| Supplementary | |
| Problem Areas | FAA Flight Crew Human Performance Aircraft Company |
| Primary Problem | Company |
Narrative:
This trip was assigned to short call reserves at XA00 PST for an XE00 departure. The identification included a ferry flight from ZZZ to pdx; 6 hour situation then a ferry flight back to ZZZ. The flight to pdx was uneventful and the captain and I went to the field hotel for scheduled rest. I had flown an all-nighter on saturday night; had only a couple hour nap on sunday; commuted to ZZZ in the evening or short call reserve resulting 3 hours sleep before being called at XA00 and then only getting an additional hour of sleep before reporting for duty. When I arrived at the hotel I took a 3 hour nap then prepared for flight back to ZZZ. The inbound flight was delayed so we departed the hotel an hour later than planned. Once the aircraft arrived; we encountered an issue trying to get omc; and deadheading crew members onto the ferry flight. This is allowed by the fom; but pdx csr's and opb were unaware of how to manifest these travelers. The captain spent quite a bit of time trying to resolve this issue. As a result of the short call reserve system; we were approaching our maximum duty day (whitlow rule) and the gdp at ZZZ we felt some urgency to depart. During the captain's cockpit set-up; he was testing the fuel xfeed valve and was interrupted. This resulted in him leaving the valve open. We completed the before start checklist but didn't catch the open xfeed valve. Normally; I look at the pumps and xfeed valve during the checklist; but due to fatigue and feeling the need to depart I didn't check this time. The engine start and departure were normal. Nearing the top of climb; we got an EICAS fuel confign with the associated light. We immediately discovered the open xfeed valve. We performed the fuel confign irregular checklist; determining that this was not a fuel leak and rebalanced the fuel. The rest of the flight was uneventful. I feel that the early morning short call reserve following the all-nighter; coupled with the XA00 notification of the trip culminated in acute fatigue. I was playing catch up with my rest during the entire day. If the xfeed valve had a guard on it; this may not have happened.
Original NASA ASRS Text
Title: FATIGUE INDUCED BY DRACONIAN SCHEDULING PRACTICES CONTRIBUTES TO A FUEL IMBALANCE ANOMALY.
Narrative: THIS TRIP WAS ASSIGNED TO SHORT CALL RESERVES AT XA00 PST FOR AN XE00 DEP. THE ID INCLUDED A FERRY FLT FROM ZZZ TO PDX; 6 HR SIT THEN A FERRY FLT BACK TO ZZZ. THE FLT TO PDX WAS UNEVENTFUL AND THE CAPT AND I WENT TO THE FIELD HOTEL FOR SCHEDULED REST. I HAD FLOWN AN ALL-NIGHTER ON SATURDAY NIGHT; HAD ONLY A COUPLE HR NAP ON SUNDAY; COMMUTED TO ZZZ IN THE EVENING OR SHORT CALL RESERVE RESULTING 3 HRS SLEEP BEFORE BEING CALLED AT XA00 AND THEN ONLY GETTING AN ADDITIONAL HR OF SLEEP BEFORE RPTING FOR DUTY. WHEN I ARRIVED AT THE HOTEL I TOOK A 3 HR NAP THEN PREPARED FOR FLT BACK TO ZZZ. THE INBOUND FLT WAS DELAYED SO WE DEPARTED THE HOTEL AN HR LATER THAN PLANNED. ONCE THE ACFT ARRIVED; WE ENCOUNTERED AN ISSUE TRYING TO GET OMC; AND DEADHEADING CREW MEMBERS ONTO THE FERRY FLT. THIS IS ALLOWED BY THE FOM; BUT PDX CSR'S AND OPB WERE UNAWARE OF HOW TO MANIFEST THESE TRAVELERS. THE CAPT SPENT QUITE A BIT OF TIME TRYING TO RESOLVE THIS ISSUE. AS A RESULT OF THE SHORT CALL RESERVE SYS; WE WERE APCHING OUR MAX DUTY DAY (WHITLOW RULE) AND THE GDP AT ZZZ WE FELT SOME URGENCY TO DEPART. DURING THE CAPT'S COCKPIT SET-UP; HE WAS TESTING THE FUEL XFEED VALVE AND WAS INTERRUPTED. THIS RESULTED IN HIM LEAVING THE VALVE OPEN. WE COMPLETED THE BEFORE START CHKLIST BUT DIDN'T CATCH THE OPEN XFEED VALVE. NORMALLY; I LOOK AT THE PUMPS AND XFEED VALVE DURING THE CHKLIST; BUT DUE TO FATIGUE AND FEELING THE NEED TO DEPART I DIDN'T CHK THIS TIME. THE ENG START AND DEP WERE NORMAL. NEARING THE TOP OF CLB; WE GOT AN EICAS FUEL CONFIGN WITH THE ASSOCIATED LIGHT. WE IMMEDIATELY DISCOVERED THE OPEN XFEED VALVE. WE PERFORMED THE FUEL CONFIGN IRREGULAR CHKLIST; DETERMINING THAT THIS WAS NOT A FUEL LEAK AND REBALANCED THE FUEL. THE REST OF THE FLT WAS UNEVENTFUL. I FEEL THAT THE EARLY MORNING SHORT CALL RESERVE FOLLOWING THE ALL-NIGHTER; COUPLED WITH THE XA00 NOTIFICATION OF THE TRIP CULMINATED IN ACUTE FATIGUE. I WAS PLAYING CATCH UP WITH MY REST DURING THE ENTIRE DAY. IF THE XFEED VALVE HAD A GUARD ON IT; THIS MAY NOT HAVE HAPPENED.
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.