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|
Attributes | |
ACN | 95461 |
Time | |
Date | 198809 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : stl airport : ord |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 15000 |
ASRS Report | 95461 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 210 flight time total : 4500 flight time type : 400 |
ASRS Report | 95703 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence other other anomaly other |
Independent Detector | other other : unspecified |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We picked up the aircraft, an large transport, in stl to fly stl-ord-stl. During the flight from stl to ord I found #2 thrust level to be out of rig. I had the flight engineer enter this in the logbook and present it to maintenance in ord. A re-rigging and full power run up was required to clear the item. The maintenance required dictated cancellation of our turnaround revenue flight. Maintenance people took the aircraft for runup west/O flight crew and accomplished the re-rigging in a runup area. The return flight to stl was conducted predominantly in IMC, at night, with a release fuel of 26000#. During climb at 330 KTS a noticeable vibration was felt throughout the airframe. Deactivation of the spoilers did not result in any change, but cracking the spoilers up stopped the problem. Stl was experiencing significant thunderstorm activity and holding delays. It bears mentioning that throughout the flight the crew was working individually and together at a fairly high workload. There was no idle conversation. Throughout the flight I noticed the aircraft required considerable retrimming. However, the yoke remained level and the slip indicator within the bars. I did not visually check the trim wheels for deflection in the darkened cockpit. There was a considerable amount of distraction with lightning and turbulence. An ILS to 12R stl was flown manually with flight director guidance and no unusual control pressures were required. After landing maintenance informed of the spoiler problem. Upon exiting the cockpit I noticed the aileron and rudder trim deflected 2-3 units right (an excessive amount) and thought it the result of compensation for a floating spoiler. On the day following the flight, I was notified by company flight operations that maintenance had found the fuel tanks unbalanced in excess of the limits. Tank 1 had 8200 pounds, 2 had 4800# and 3 had 2050#. They informed me that xfeed valve confign was #1 open, #2 closed and #3 open. With a 26000# fuel load on the feed is normally tank to engine with xfeeds set #1 closed, #2 open (to pressurized manifold), #3 closed. A mirror image of the xfeeds as found after secure in stl. A fuel log is not required by company policy on stage lengths with cruise less than 30 mins as this flight was. Also the fuel totalizer may be used as reference for fuel on board on shorter legs, but does specify that the individual tank quantities should be crosschecked. It seems that the following explanation most accurately describes the possible causes of this incident. The F/east came off the previous leg with the FAA on board checking her for check airman status. High stress with high visibility. Maintenance in ord took the aircraft (properly configured) and probably reconfigured the xfeeds for run up. Aircraft was delivered to the flight crew with xfeeds in mirror image. The engineer probably misread the valve confign as can so easily be done when a pattern is what you are looking for. Tank #3 overpwred 1 and fed both engine 1 and 3. The high workload precluded the opportunity to xchk fuel gauges and the tendency would be to assume normal burn considering tank to engine confign. The spoiler problem compounded the confusion and directed the entire crews attention from the trimming imbalance. The short leg required no fuel log to be kept en route. Ps: subsequent investigation showed that: maintenance ord had in fact reconfigured the xfeeds and ran the tanks out of balance during run up.
Original NASA ASRS Text
Title: ACR LGT FUEL IMBALANCE CAUSED BY IMPROPER FUEL MANAGEMENT BY FLT CREW.
Narrative: WE PICKED UP THE ACFT, AN LGT, IN STL TO FLY STL-ORD-STL. DURING THE FLT FROM STL TO ORD I FOUND #2 THRUST LEVEL TO BE OUT OF RIG. I HAD THE FE ENTER THIS IN THE LOGBOOK AND PRESENT IT TO MAINT IN ORD. A RE-RIGGING AND FULL PWR RUN UP WAS REQUIRED TO CLEAR THE ITEM. THE MAINT REQUIRED DICTATED CANCELLATION OF OUR TURNAROUND REVENUE FLT. MAINT PEOPLE TOOK THE ACFT FOR RUNUP W/O FLC AND ACCOMPLISHED THE RE-RIGGING IN A RUNUP AREA. THE RETURN FLT TO STL WAS CONDUCTED PREDOMINANTLY IN IMC, AT NIGHT, WITH A RELEASE FUEL OF 26000#. DURING CLB AT 330 KTS A NOTICEABLE VIBRATION WAS FELT THROUGHOUT THE AIRFRAME. DEACTIVATION OF THE SPOILERS DID NOT RESULT IN ANY CHANGE, BUT CRACKING THE SPOILERS UP STOPPED THE PROB. STL WAS EXPERIENCING SIGNIFICANT TSTM ACTIVITY AND HOLDING DELAYS. IT BEARS MENTIONING THAT THROUGHOUT THE FLT THE CREW WAS WORKING INDIVIDUALLY AND TOGETHER AT A FAIRLY HIGH WORKLOAD. THERE WAS NO IDLE CONVERSATION. THROUGHOUT THE FLT I NOTICED THE ACFT REQUIRED CONSIDERABLE RETRIMMING. HOWEVER, THE YOKE REMAINED LEVEL AND THE SLIP INDICATOR WITHIN THE BARS. I DID NOT VISUALLY CHK THE TRIM WHEELS FOR DEFLECTION IN THE DARKENED COCKPIT. THERE WAS A CONSIDERABLE AMOUNT OF DISTR WITH LIGHTNING AND TURB. AN ILS TO 12R STL WAS FLOWN MANUALLY WITH FLT DIRECTOR GUIDANCE AND NO UNUSUAL CONTROL PRESSURES WERE REQUIRED. AFTER LNDG MAINT INFORMED OF THE SPOILER PROB. UPON EXITING THE COCKPIT I NOTICED THE AILERON AND RUDDER TRIM DEFLECTED 2-3 UNITS R (AN EXCESSIVE AMOUNT) AND THOUGHT IT THE RESULT OF COMPENSATION FOR A FLOATING SPOILER. ON THE DAY FOLLOWING THE FLT, I WAS NOTIFIED BY COMPANY FLT OPS THAT MAINT HAD FOUND THE FUEL TANKS UNBALANCED IN EXCESS OF THE LIMITS. TANK 1 HAD 8200 LBS, 2 HAD 4800# AND 3 HAD 2050#. THEY INFORMED ME THAT XFEED VALVE CONFIGN WAS #1 OPEN, #2 CLOSED AND #3 OPEN. WITH A 26000# FUEL LOAD ON THE FEED IS NORMALLY TANK TO ENG WITH XFEEDS SET #1 CLOSED, #2 OPEN (TO PRESSURIZED MANIFOLD), #3 CLOSED. A MIRROR IMAGE OF THE XFEEDS AS FOUND AFTER SECURE IN STL. A FUEL LOG IS NOT REQUIRED BY COMPANY POLICY ON STAGE LENGTHS WITH CRUISE LESS THAN 30 MINS AS THIS FLT WAS. ALSO THE FUEL TOTALIZER MAY BE USED AS REF FOR FUEL ON BOARD ON SHORTER LEGS, BUT DOES SPECIFY THAT THE INDIVIDUAL TANK QUANTITIES SHOULD BE XCHKED. IT SEEMS THAT THE FOLLOWING EXPLANATION MOST ACCURATELY DESCRIBES THE POSSIBLE CAUSES OF THIS INCIDENT. THE F/E CAME OFF THE PREVIOUS LEG WITH THE FAA ON BOARD CHKING HER FOR CHK AIRMAN STATUS. HIGH STRESS WITH HIGH VISIBILITY. MAINT IN ORD TOOK THE ACFT (PROPERLY CONFIGURED) AND PROBABLY RECONFIGURED THE XFEEDS FOR RUN UP. ACFT WAS DELIVERED TO THE FLC WITH XFEEDS IN MIRROR IMAGE. THE ENGINEER PROBABLY MISREAD THE VALVE CONFIGN AS CAN SO EASILY BE DONE WHEN A PATTERN IS WHAT YOU ARE LOOKING FOR. TANK #3 OVERPWRED 1 AND FED BOTH ENG 1 AND 3. THE HIGH WORKLOAD PRECLUDED THE OPPORTUNITY TO XCHK FUEL GAUGES AND THE TENDENCY WOULD BE TO ASSUME NORMAL BURN CONSIDERING TANK TO ENG CONFIGN. THE SPOILER PROB COMPOUNDED THE CONFUSION AND DIRECTED THE ENTIRE CREWS ATTN FROM THE TRIMMING IMBALANCE. THE SHORT LEG REQUIRED NO FUEL LOG TO BE KEPT ENRTE. PS: SUBSEQUENT INVESTIGATION SHOWED THAT: MAINT ORD HAD IN FACT RECONFIGURED THE XFEEDS AND RAN THE TANKS OUT OF BAL DURING RUN UP.
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.