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Attributes | |
ACN | 86666 |
Time | |
Date | 198805 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : nrt |
State Reference | FO |
Altitude | msl bound lower : 36000 msl bound upper : 36000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa artcc : rjtg artcc : zdc |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : pacific enroute : other oceanic enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 175 flight time total : 20000 flight time type : 175 |
ASRS Report | 86666 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 18090 flight time type : 500 |
ASRS Report | 86668 |
Events | |
Anomaly | aircraft equipment problem : critical |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : declared emergency none taken : unable |
Consequence | faa : investigated Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Narrative:
Flight departed lax 5/88, destination tokyo, japan. The flight crew consisted of the following: captain, first officer and second officer. Passenger count was 259. There were 14 F/a's. Takeoff fuel load 312000#. Departure, takeoff, climb and cruise were normal in all respects. Approximately 4 hours into the flight, the second officer brought to the attention of the captain an apparent fuel imbalance between fuel tanks. This aircraft does not have a flow equalization valve in the xfeed system. Fuel management procedures were normal to this time. Normal fuel balancing procedures were initiated, but results did not appear satisfactory. Xfeed valves and boost pumps appeared to operate normally. Previous aircraft logbook write ups indicated probable aircraft fuel gauge problems. Fuel system, xfeed valve in transit lights indicated movement of xfeed valves to desired positioning at all times. Captain and second officer entered into problem resolution while first officer focused on navigation and plting duties. As the flight progressed further toward narita, the apparent fuel discrepancies increased. An aircraft trim check was made and the aileron trim did not match the fuel load as configured on the gauges. The flight crew continued to be reassured that the fuel quantity gauges were inaccurate until the #4 engine flamed out. The engine relit almost immediately and ran well for 35 mins. At this time, engines #1, 3 and 4 flamed out due to fuel starvation. The aircraft position was 186 mi east of narita. The first officer declared an emergency and tokyo control cleared the flight to 10000'. A descent profile approximating 250 KTS, indicated airspeed and 500 FPM descent allowed the aircraft to arrive in a position to conduct an approach and landing at narita west/O further incident. All xfeed valves were checked on the ground at narita by company maintenance personnel and all operated normally. The aircraft was ferried back to san francisco. However, 2 xfeed valves froze in the open position during flight approximately 3 1/2 hours after takeoff from narita. An irregular procedure utilizing the fuel jettison system is used by company to move fuel from an inboard tank when an inboard tank xfeed valve is inoperative. The xfeed valve intransit lights indicated normal operation on this flight. Company specifically prohibited use of this procedure to balance fuel on this date. Consequently, the crew did not use this procedure. Company has now authorized the use of this irregular procedure to balance fuel when the inboard tanks are out of balance. In addition, company is now inserting fuel equalization valves into aircraft and the other new widebody transport. Callback conversation with reporter revealed the following: the reporter has not been able to solve the mystery of why the #2 xfeed valve indicated open when in fact it was frozen in the closed position. Second officer maintains he saw normal transit light indications whenever he changed a valve position. Mfr could not verify that the transfer light could appear to operate normally when the valve did not move as selected. Maintenance history on this particular aircraft indicated repeated fuel indication problems that have since been determined to be the results of a combination of xfeed valve problems and no equalizer valves in the manifold. The flight crew knew they had enough fuel to reach their destination and did careful logging of fuel burn throughout the flight. They became convinced that they had fuel indication irregularities when they could not match aircraft trim to the fuel imbalance they observed on the gauges, but knowing they had sufficient fuel they continued on in the belief that if they turned all xfeeds and fuel pumps on the engine would continue to operated. Post-flight inspection revealed a 10600# fuel flow differential between #2 and #3 main tanks. Also revealed was that the #2 valve motor would not operate at low temperature and the #4 xfeed valve motor suffered electrical power loss through the cannon plug at low temperatures. Use of jettison system was not included in the training the captain received and apparently the first officer and second officer, knowing that a company bulletin had been issued restricting the use of this system, never discussed its use. The flight crew is on special assignment until they requalify on the widebody transport. A more complete NTSB and FAA report has been filed along with a company report.
Original NASA ASRS Text
Title: FUEL EXHAUSTION CAUSING 3 ENGINES TO FLAME OUT AT THE END OF AN EXTENDED OVER WATER OPERATION. ACFT CONTINUED DESCENT TO DESTINATION WITN 1 ENGINE OPERATING.
Narrative: FLT DEPARTED LAX 5/88, DEST TOKYO, JAPAN. THE FLT CREW CONSISTED OF THE FOLLOWING: CAPT, F/O AND S/O. PAX COUNT WAS 259. THERE WERE 14 F/A'S. TKOF FUEL LOAD 312000#. DEP, TKOF, CLB AND CRUISE WERE NORMAL IN ALL RESPECTS. APPROX 4 HRS INTO THE FLT, THE S/O BROUGHT TO THE ATTN OF THE CAPT AN APPARENT FUEL IMBALANCE BTWN FUEL TANKS. THIS ACFT DOES NOT HAVE A FLOW EQUALIZATION VALVE IN THE XFEED SYS. FUEL MGMNT PROCS WERE NORMAL TO THIS TIME. NORMAL FUEL BALANCING PROCS WERE INITIATED, BUT RESULTS DID NOT APPEAR SATISFACTORY. XFEED VALVES AND BOOST PUMPS APPEARED TO OPERATE NORMALLY. PREVIOUS ACFT LOGBOOK WRITE UPS INDICATED PROBABLE ACFT FUEL GAUGE PROBS. FUEL SYS, XFEED VALVE IN TRANSIT LIGHTS INDICATED MOVEMENT OF XFEED VALVES TO DESIRED POSITIONING AT ALL TIMES. CAPT AND S/O ENTERED INTO PROB RESOLUTION WHILE F/O FOCUSED ON NAV AND PLTING DUTIES. AS THE FLT PROGRESSED FURTHER TOWARD NARITA, THE APPARENT FUEL DISCREPANCIES INCREASED. AN ACFT TRIM CHK WAS MADE AND THE AILERON TRIM DID NOT MATCH THE FUEL LOAD AS CONFIGURED ON THE GAUGES. THE FLT CREW CONTINUED TO BE REASSURED THAT THE FUEL QUANTITY GAUGES WERE INACCURATE UNTIL THE #4 ENG FLAMED OUT. THE ENG RELIT ALMOST IMMEDIATELY AND RAN WELL FOR 35 MINS. AT THIS TIME, ENGS #1, 3 AND 4 FLAMED OUT DUE TO FUEL STARVATION. THE ACFT POS WAS 186 MI E OF NARITA. THE F/O DECLARED AN EMER AND TOKYO CTL CLRED THE FLT TO 10000'. A DSCNT PROFILE APPROXIMATING 250 KTS, INDICATED AIRSPD AND 500 FPM DSCNT ALLOWED THE ACFT TO ARRIVE IN A POS TO CONDUCT AN APCH AND LNDG AT NARITA W/O FURTHER INCIDENT. ALL XFEED VALVES WERE CHKED ON THE GND AT NARITA BY COMPANY MAINT PERSONNEL AND ALL OPERATED NORMALLY. THE ACFT WAS FERRIED BACK TO SAN FRANCISCO. HOWEVER, 2 XFEED VALVES FROZE IN THE OPEN POS DURING FLT APPROX 3 1/2 HRS AFTER TKOF FROM NARITA. AN IRREGULAR PROC UTILIZING THE FUEL JETTISON SYS IS USED BY COMPANY TO MOVE FUEL FROM AN INBOARD TANK WHEN AN INBOARD TANK XFEED VALVE IS INOP. THE XFEED VALVE INTRANSIT LIGHTS INDICATED NORMAL OPERATION ON THIS FLT. COMPANY SPECIFICALLY PROHIBITED USE OF THIS PROC TO BALANCE FUEL ON THIS DATE. CONSEQUENTLY, THE CREW DID NOT USE THIS PROC. COMPANY HAS NOW AUTHORIZED THE USE OF THIS IRREGULAR PROC TO BALANCE FUEL WHEN THE INBOARD TANKS ARE OUT OF BALANCE. IN ADDITION, COMPANY IS NOW INSERTING FUEL EQUALIZATION VALVES INTO ACFT AND THE OTHER NEW WDB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: THE RPTR HAS NOT BEEN ABLE TO SOLVE THE MYSTERY OF WHY THE #2 XFEED VALVE INDICATED OPEN WHEN IN FACT IT WAS FROZEN IN THE CLOSED POS. S/O MAINTAINS HE SAW NORMAL TRANSIT LIGHT INDICATIONS WHENEVER HE CHANGED A VALVE POS. MFR COULD NOT VERIFY THAT THE TRANSFER LIGHT COULD APPEAR TO OPERATE NORMALLY WHEN THE VALVE DID NOT MOVE AS SELECTED. MAINT HISTORY ON THIS PARTICULAR ACFT INDICATED REPEATED FUEL INDICATION PROBS THAT HAVE SINCE BEEN DETERMINED TO BE THE RESULTS OF A COMBINATION OF XFEED VALVE PROBS AND NO EQUALIZER VALVES IN THE MANIFOLD. THE FLT CREW KNEW THEY HAD ENOUGH FUEL TO REACH THEIR DEST AND DID CAREFUL LOGGING OF FUEL BURN THROUGHOUT THE FLT. THEY BECAME CONVINCED THAT THEY HAD FUEL INDICATION IRREGULARITIES WHEN THEY COULD NOT MATCH ACFT TRIM TO THE FUEL IMBALANCE THEY OBSERVED ON THE GAUGES, BUT KNOWING THEY HAD SUFFICIENT FUEL THEY CONTINUED ON IN THE BELIEF THAT IF THEY TURNED ALL XFEEDS AND FUEL PUMPS ON THE ENG WOULD CONTINUE TO OPERATED. POST-FLT INSPECTION REVEALED A 10600# FUEL FLOW DIFFERENTIAL BTWN #2 AND #3 MAIN TANKS. ALSO REVEALED WAS THAT THE #2 VALVE MOTOR WOULD NOT OPERATE AT LOW TEMP AND THE #4 XFEED VALVE MOTOR SUFFERED ELECTRICAL PWR LOSS THROUGH THE CANNON PLUG AT LOW TEMPS. USE OF JETTISON SYS WAS NOT INCLUDED IN THE TRNING THE CAPT RECEIVED AND APPARENTLY THE F/O AND S/O, KNOWING THAT A COMPANY BULLETIN HAD BEEN ISSUED RESTRICTING THE USE OF THIS SYS, NEVER DISCUSSED ITS USE. THE FLT CREW IS ON SPECIAL ASSIGNMENT UNTIL THEY REQUALIFY ON THE WDB. A MORE COMPLETE NTSB AND FAA RPT HAS BEEN FILED ALONG WITH A COMPANY RPT.
Data retrieved from NASA's ASRS site as of August 2007 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.