Number 274
June 2002
Gotta Refuel? Follow the Rules
An incident reported to ASRS by an air carrier First Officer describes what can happen when fuel load and balance problems are not detected before takeoff. s Flight was preparing to depart. Gave fueler the fuel load of 1,400 pounds a side, or 2,800 pounds total. Aircraft had 700 pounds a side prior to fueling. Fuel was received and confirmed by ‘before start checklist’ as 1,400 pounds a side as requested. Walkaround after fueling verified that there were no fuel leaks or abnormalities, and fuel service panel was shut properly. Engine start was normal and we taxied for approximately 15 minutes to Runway 26L. I performed the takeoff and noted a large right wing down tendency upon liftoff. When scanning the instruments, I noted that all of the fuel from the left wing had somehow transferred into the right wing tank, resulting in a 2,500-2,600 pound imbalance. When we realized this, we decided to return to the field asap. About 1 minute later, passing about 2,000 feet, the left engine flamed out due to no fuel in the left tank. The fuel crossfeed was not open, and there is no way to transfer fuel from wing-to-wing by pilot action. We performed the engine failure checklist and declared an emergency. We were vectored for a visual approach to Runway 26R and landed without incident… Upon shutdown at the gate, maintenance personnel opened the fueling panel and found several switches on the fueling panel still on, including a defuel switch, which is never supposed to be used in normal fueling and should have been safety-wired closed. Training manuals state these switches are to be used by maintenance only and can cause L FUE fuel to transfer from tank-to-tank if left open with the electric boost pumps on. Contributing cause was also a broken device on the fuel door which contacts the switch covers, closing the switch when the panel is closed to prevent the switches from being left open. No one knew why the defuel switch was open to begin with. We were questioned as to whether the fuel imbalance existed after fueling and we failed to notice it, but the Captain and I were positive fuel was balanced after fueling. This was later confirmed by a test fueling with the defuel switch open, which resulted in proper fuel balance. After the ‘before start checklist,’ there is no other checklist prior to takeoff which calls for rechecking fuel quantity or balance. The company is investigating the problem. Many air carriers include ‘Fuel Balance/Crossfeed’ not only on the Before-Start and Before-Takeoff checklists, but also on the Climb, Cruise, and Descent checklists.
Plane Makes Hay, But Not Airport
A flight instructor learned that use of a checklist by a student during preflight is no guarantee that fuel quantity has been properly verified. s Returning from training flight with student. Approximately 5-7 nm northeast of downtown [airport], the engine lost power and then surged several times. The fuel gauges appeared to be at or near empty. The plane was headed into a 20+ knot headwind. Making it to [the airport] seemed doubtful at best. [I] decided to look for a safe landing area. The nearest and only one was a farmer’s hay field. I notified the Tower of my intention and landed safely. I taxied to the highest spot in the center of the field, notified the Tower and remained in radio contact until another aircraft reported us to the Tower. The engine did not stop running until shut down on the ground… Before the flight, I observed the student using the checklist to conduct the pre-flight. He said everything was “ok” and ready to go. On run-up before takeoff, I casually observed the fuel gauges as below one-half full. The procedure followed by the company is to not completely fill the tanks due to the danger of overgross weight problems. The student who conducted the preflight told the Chief Pilot that he felt fuel in the tanks when he stuck his finger in the fill tube. The lack of definite measurement, strong headwinds, and not adding some fuel made this incident take the course it did. As everyone learns in Aviation 101, any attempt to stretch fuel is guaranteed to increase headwinds. This student and instructor demonstrated lack of safety teamwork. The fuel quantity was not double-checked on preflight by the instructor. Both pilots ignored the low fuel reading on run-up and failed to consider the fuel implications of flying into strong headwinds. Finally, the fuel burn during flight was not adequately monitored. Ultimately, the instructor must take responsibility for the aircraft’s off-field landing.
ASRS Recently Issued Alerts On…
A-319 emergency slide event BE-55 partial gear extension failure Recurring false GPWS and EPWS terrain alerts Incidents of runway obstruction by seagoing vessels Recurring A-319/A-320 brake flange access problems
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/
April 2002 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2261 880 54 140 3335
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_274.pdf
June 2002
Gotta Refuel? Follow the Rules
An incident reported to ASRS by an air carrier First Officer describes what can happen when fuel load and balance problems are not detected before takeoff. s Flight was preparing to depart. Gave fueler the fuel load of 1,400 pounds a side, or 2,800 pounds total. Aircraft had 700 pounds a side prior to fueling. Fuel was received and confirmed by ‘before start checklist’ as 1,400 pounds a side as requested. Walkaround after fueling verified that there were no fuel leaks or abnormalities, and fuel service panel was shut properly. Engine start was normal and we taxied for approximately 15 minutes to Runway 26L. I performed the takeoff and noted a large right wing down tendency upon liftoff. When scanning the instruments, I noted that all of the fuel from the left wing had somehow transferred into the right wing tank, resulting in a 2,500-2,600 pound imbalance. When we realized this, we decided to return to the field asap. About 1 minute later, passing about 2,000 feet, the left engine flamed out due to no fuel in the left tank. The fuel crossfeed was not open, and there is no way to transfer fuel from wing-to-wing by pilot action. We performed the engine failure checklist and declared an emergency. We were vectored for a visual approach to Runway 26R and landed without incident… Upon shutdown at the gate, maintenance personnel opened the fueling panel and found several switches on the fueling panel still on, including a defuel switch, which is never supposed to be used in normal fueling and should have been safety-wired closed. Training manuals state these switches are to be used by maintenance only and can cause L FUE fuel to transfer from tank-to-tank if left open with the electric boost pumps on. Contributing cause was also a broken device on the fuel door which contacts the switch covers, closing the switch when the panel is closed to prevent the switches from being left open. No one knew why the defuel switch was open to begin with. We were questioned as to whether the fuel imbalance existed after fueling and we failed to notice it, but the Captain and I were positive fuel was balanced after fueling. This was later confirmed by a test fueling with the defuel switch open, which resulted in proper fuel balance. After the ‘before start checklist,’ there is no other checklist prior to takeoff which calls for rechecking fuel quantity or balance. The company is investigating the problem. Many air carriers include ‘Fuel Balance/Crossfeed’ not only on the Before-Start and Before-Takeoff checklists, but also on the Climb, Cruise, and Descent checklists.
Plane Makes Hay, But Not Airport
A flight instructor learned that use of a checklist by a student during preflight is no guarantee that fuel quantity has been properly verified. s Returning from training flight with student. Approximately 5-7 nm northeast of downtown [airport], the engine lost power and then surged several times. The fuel gauges appeared to be at or near empty. The plane was headed into a 20+ knot headwind. Making it to [the airport] seemed doubtful at best. [I] decided to look for a safe landing area. The nearest and only one was a farmer’s hay field. I notified the Tower of my intention and landed safely. I taxied to the highest spot in the center of the field, notified the Tower and remained in radio contact until another aircraft reported us to the Tower. The engine did not stop running until shut down on the ground… Before the flight, I observed the student using the checklist to conduct the pre-flight. He said everything was “ok” and ready to go. On run-up before takeoff, I casually observed the fuel gauges as below one-half full. The procedure followed by the company is to not completely fill the tanks due to the danger of overgross weight problems. The student who conducted the preflight told the Chief Pilot that he felt fuel in the tanks when he stuck his finger in the fill tube. The lack of definite measurement, strong headwinds, and not adding some fuel made this incident take the course it did. As everyone learns in Aviation 101, any attempt to stretch fuel is guaranteed to increase headwinds. This student and instructor demonstrated lack of safety teamwork. The fuel quantity was not double-checked on preflight by the instructor. Both pilots ignored the low fuel reading on run-up and failed to consider the fuel implications of flying into strong headwinds. Finally, the fuel burn during flight was not adequately monitored. Ultimately, the instructor must take responsibility for the aircraft’s off-field landing.
ASRS Recently Issued Alerts On…
A-319 emergency slide event BE-55 partial gear extension failure Recurring false GPWS and EPWS terrain alerts Incidents of runway obstruction by seagoing vessels Recurring A-319/A-320 brake flange access problems
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/
April 2002 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2261 880 54 140 3335
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_274.pdf
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