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美国ASRS安全公告CALLBACK cb_264.pdf2页

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Number 264

August 2001

Fuel Considerations for Multi-Crew Operations
Fuel starvation is a potential hazard to multi-crew as well as single-pilot operations. An air carrier line check Captain describes what can happen when a task that is usually automated – in this case fuel balancing – must be performed manually in a cockpit climate punctuated by radio calls and training requirements. Captain was monitoring Center on VHF #1. After the radio check, I announced I was going to terminate the fuel [crossfeed]. Just as I reached up to turn on the #2 tank pump for fuel feed to the #2 engine, ATC called with our [foreign ATC] handoff. As my finger went forward to press the tank pump, I looked down to copy the handoff frequency. Somehow I pushed the crossfeed switch instead. (A contributing factor was that a guard…supposed to be on the pump switch was left off by maintenance when they changed the controller the previous flight)… The #2 engine rolled back, as I saw this. I looked at the fuel schematic and saw no fuel line to the #2 engine. I…selected the #2 tank pump to ‘on’… and the #2 [engine] returned to operation. We continued a normal flight to destination. The need to manage concurrent tasks is an everyday part of cockpit operations that can become unbalanced by interruptions and distractions. ASRS Directline Issue 10, available on the ASRS web site (http://asrs.arc.nasa.gov), offers a summary of strategies for reducing vulnerability to task management errors.

s We were dispatched with the fuel system controller inoperative, a highly unusual situation. While in cruise en route, a disparity was noticed between the fuel quantities in the #1, #2, and #3 tanks. We were just prior to our entry point for [foreign country’s] overflight and I wanted everything to be in order for this phase of flight. I began a fuel [crossfeed] from the #1 and #3 tanks to the #2 engine.
As the crossfeed was nearing its conclusion, a sudden flurry of radio calls created a distraction. I was in the right seat as a Line Check Airman giving IOE [Initial Operating Experience] to a new Captain. Center called for a radio check on another frequency. I tuned #2 VHF to this frequency and made the check. It took several calls to get a good check. The IOE

“Who’s on First, What’s on Second?”
additional fuel and the fueler mistakenly added approximately 6,000 lbs. in the center wing of aircraft ‘X.’ We noticed the increased fuel just prior to pushback, but failed to realize this put us overweight for taxi by about 1,000 lbs. and entered an updated fuel of 87.2K. The aircraft was pushed back, engines started, and then a s Aircraft for Flight ‘X’ for airport ABC and Flight ‘Y’ for message from Load Control was observed on ACARS airport BCD were changed without explanation and the alerting us to a probable overweight taxi situation. I flight for airport ABC was rescheduled to accommodate stopped the aircraft while a final determination was made, passengers for airport BCD. 82,000 lbs. of fuel [were] needed then taxied back to the gate where sufficient cargo was for the leg to BCD. Dispatch fuel to airport ABC was about offloaded and a required maintenance inspection 74,000 lbs. Rather than defuel, the current load was accomplished. A combination of errors, but ultimately my acceptable and within limits for the flight to ABC. fault for missing the change in gross weight. Unknown to us, the crew for Flight ‘Y’ had requested Take two company B-767s bound for cities on the same coast, put them on the same ramp, swap one aircraft’s destination with the other’s, and what have you got? A set-up for a fuel loading error. More from this Captain’s report (Abbott and Costello didn’t write this, honest):

‘Sound Bites’ from ASRS Reporters
ASRS recently received a report from an experienced pilot who takes fellow pilots and ATC to task for cluttering Tower frequencies with unnecessary communications:
AERONAUTICAL INFORMATION MANUAL/FEDERAL AVIATION REGULATIONS

bother with the unnecessary call. At other times the Tower actually gives permission without the request, reinforcing the incorrect idea that permission is required… Help! In the words of the Aeronautical Information Manual (AIM): AIM, Section 3, 4-3-2(a). “…It is a good operating practice to remain on the Tower frequency for the purpose of receiving traffic information. In the interest of reducing Tower frequency congestion, pilots are reminded that it is not necessary to request permission to leave the Tower frequency once outside of Class B, Class C, and Class D surface areas…”

s This is…a plea for you to publish

something on the subject in your [CALLBACK] mailer. Pilots and controllers both ignore AIM 4-3-2 that states, “it is not necessary to request permission to leave Tower frequency.” Almost every day I fly some pilot has to take up valuable air time making multiple requests to change frequencies at times when everyone is just too busy to

ASRS Recently Issued Alerts On…
Non-standard hold lines at a Midwest airport Inflight activation of a G-IV stall barrier system Fokker-100 loss of rudder control on short final Uncoordinated Mode C testing by maintenance at a FBO An airport’s ground holding procedures for landing aircraft

A Monthly Safety Bulletin from
The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://asrs.arc.nasa.gov/

June 2001 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2232 729 81 193 3235


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