Always pay attention to your fuel status

[neville_nobody]

Or else this kinda stuff happens:

http://www.atsb.gov.au/publications/investigation_reports/2007/AAIR/aair200705093.aspx

[ScottyDoo]

How about cut-and-paste-and-post so the lazy amongst us don't have to open new stuff.

Can't be bothered... :zzz:

[neville_nobody]

God help you in GA then............................:}:} Gen Y :ugh::hmm:

[ScottyDoo]

Not in GA!!!

[pithblot]

Not in GA! Then G-EAOU :)

[training wheels]

Here you go guys .. no sweat. :)

On 11 August 2007, a Boeing 737-476 aircraft, registered VH-TJE, was being operated on a scheduled passenger service between Perth, WA to Sydney, NSW. The flight crew consisted of a pilot in command, who was the pilot flying, and a copilot. The aircraft took off from Perth at 0544 Western Standard Time. About 2 hours 40 minutes later, the master caution light illuminated associated with low output pressure of the aircrafts main tank fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position.

The main fuel tanks were low on fuel and the investigation estimated that there was about 100 kg in each of the main tanks. The centre fuel tank contained about 4,700 kg of fuel when the master caution occurred. The flight continued on the flight planned route and landed at Sydney 51 minutes after the initial illumination of the master caution light.

The investigation is continuing.

[Capt Kremin]

Guys this incident was the subject of another thread which was locked. I am not trying to stifle debate here, but should you wish to comment, be aware that the crew has already suffered considerable ramifications as a result of this incident. Please bear that in mind.

[Jet Jockey]

What the @#*&
Surely the sky gods master of the universe and everything else could not make such a basic mistake with all their superior training. ??????

[ScottyDoo]

Anyone can.

Thanks for posting it.

[squawk6969]

Capt Kremin

For those of us who do not know, exactly what are those ramifications?

SQ

[Captain Sherm]

Good point.....tell us what happened so we can learn Captain K.
I could easily have done this (mistake) myself but for the fact that for years have been flying a type that tells you via EICAS if you have fuel in centre tanks but the pumps aren't on. We all need to learn.

[Capt Kremin]

Demotion for the captain... nuff said.

[Servo]

There for but the grace of god go I............. that is why I never comment on someone else's "misfortune"

As long as we ALL learn from it, no one is immune to making mistakes.

I learnt the other day a hard lesson, dont trust your offsider, NEVER assume they have done the job properly.

Regards,


Servo

[Thai997]

Were there other issues that lead to a demotion ??

Seems very harsh punishment for was was essentially a human factors related event (ie not a deliberate SOP violation).

What does this do for the reporting culture at QF ?

[UnderneathTheRadar]

Based purely on the speculation of the earlier thread, the key to action against the crew may lie in of the further investigation items listed in the ATSB report:

- post flight actions

Otherwise it does seem a bit draconian.....

UTR

[Poto]

What does this do for the reporting culture at QF ?

I don't think it was reported:confused: - part of the issue here.

[fergusdog]

JET JOCKSTRAP U MUST BE FROM THE JSTAR:mad:

[squawk6969]

So I think I get it here......engineers told to shift fuel, coz she's a bit full in the guts......hope nobody noticed!

I feel if that was my crew, I would rather here a ...."hey boss we fecked up here, where is the incident forms, lets all not make this mistake again hey!"

And after some refressher training of sorts......back to work coz now you are a far more valuable asset around here from experience........one would hope.

But if you dont have that kind of management and you have a feeling that its better to try to hide it......this is what happens.

What ever happened to people being able to stick their hand up and say ....ooops, sorry, and then be proactive?

I thought that was the best way to move forward, rather than a culture of cover up ad then humiliate!

SQ

PS: Servo...where you the skipper?

[sayallafter]

Maybe the check list would be better to have a requirment to state the number of pumps on....ala.......13000 kg, 6 pumps on.

[Centaurus]

Maybe the revised (2006) Boeing checklist design had something to do with the initial fuel tank faulty selection process. With the first officer now over-loaded with about 80 percent of the pre-start scans and other cockpit checks - plus he now has to read, challenge and respond to his own voice and the captain " managing by observing" while the first officer's hands are flashing all over the various panels, is it any wonder that occasional balls-ups occur. Most go unreported - after all no point in cutting your own throat..

[Capt Fathom]

Maybe the check list would be better to have a requirment to state the number of pumps on....ala.......13000 kg, 6 pumps on.

"13000 kg, 6 pumps on" That just rolls of the tongue as part of the checklist reading.

But will the pumps be ON? Maybe. Maybe not!

Checklists can lead to complacency. You merely read then respond with what should be set.

[Flight Me]

Initial threats to this flight are unknown, however from this thread the threat is that of fuel starvation in the wing tanks due to the centre pump being in the off position. Was the threat recognised - yes. Was an error made, initially yes, was the error recognised - yes, the outcome was inconsequentional.

Seems to me that they have some sort of threat and error management in place and it worked. Maybe some retraining in the new checks or as the case may be. To me post flight should consist of a 1 page summary of the threats, errors and consequences for all crew to read and learn from. We are human and we need to stick together and learn from one another, at the end of the day we all share the same sky.

From LOSA (4500 Flights) 80% of all flights have some form of error, of these 25% are mismanaged, 6% lead to additional errors and 19% lead to undesired aircraft states. We all have a part to play.

My verdict, well done to the crew for identifying the error, I hope you have learnt from it. I do not fly jets, none the less we all have fuel on board. I have learnt from it.

[The Mr Fixit]

Quit the BS

Anyone who flies or fixes the 737 know exactly what has occurred and why they were in such a position after flying from PER. :hmm:

The penalty is applied for what occurred afterwards (not that I feel it was suitable), I feel for all involved as I thought the white rat was a just culture. pffffffffffffffttt :eek:

"THERE FOR THE GRACE OF GOD GO I" how true a statement :D

A colleague of mine says "A man who never made a mistake, never made anything"

Lets all live and learn :ok:

[Lasiorhinus]

Quit the BS

Anyone who flies or fixes the 737 know exactly what has occurred and why they were in such a position after flying from PER.

And those of us who don't fly 737s have no idea what occurred. Care to enlighten us?

[Centaurus]

Initial threats to this flight are unknown, however from this thread the threat is that of fuel starvation in the wing tanks due to the centre pump being in the off position. Was the threat recognised - yes. Was an error made, initially yes, was the error recognised - yes, the outcome was inconsequentional
Excuse me old chap - is your name Kevin Rudd? You certainly have his self question and answer style. And what's all this "Threat and Error" crap? Speak plain English, please..

[umopap!sdn]

TEM:rolleyes:

[lambsie]

Were the poor, oblivious customers down the back aware that they were minutes from a double engine flameout? I think not.

Is it even possible to relight a 737 with only centre tank fuel?

This has potential CATASTROPHE written all over it.

The fact that the event was initially reported by the receiving engineer, not the crew, is grounds for dismissal, not demotion.

[A37575]

Seems to me that they have some sort of threat and error management in place and it worked.

You mean like slipping on a condom before knocking off a potentially fertile woman!

[C441]

You should be a journo Lambsie!
All that's missing is a "yeah, we knew there was something wrong when we heard the engines backfire" quote from a terrified passenger.
Factual investigative reports can often overlook the subtle exterior, often personal, influences that lead to this sort of incident.

Educate yourself before you condemn a guilty but flawed person or system.

[Jabawocky]

Lambsie

Good question to ask! I hope we get some sensible answers, I would think if you can feed the engines, you can light them up. However I do believe you may not be able to restart at altitude, so a restart might have to be attempted after being a glider for a while.

Plenty of time to read the manual........:E

[Captain Sherm]

Never (thank goodness) flew the Slug. But if its is anything like the DC9 or MD80 you could die with lots of fuel in the center tank. Both engines flamed out and no way for them or APU to get the gas.
Thats why Captain K, there's such interest in this......as I read, the PIC had 10,000 hours or so on the Slug....that alone tells us a lot about the holes in the cheese....don't just tap the side of your nose and say "nuff said".....this was minutes from black armbands......share with your colleagues.......please

[Capt Kremin]

The facts are broadly known and I have nothing to add to that. I don't fly the 737 either. My concern is for the crew. Having said that, had they self reported, the outcome would have been much different.

[Flight Me]

Centaurus, The figures do in fact come from TEM's training. A course which I believe is going to become compulsary for all pilots. My thinking has certainly changed since the course in so much as that I am always challenging checklists, procedures and the way I do things and looking for potential threats. If this means that a checklist or procedure should be changed then, outline the threat and potential consequences and have it sorted.

My backing of the pilots here is merely at rumour value. All the facts are not on the table on this forum non the less disaster has been avoided. The outcome could of been completely different, if it were we would have everyone on this site offering condolences and sympathy, probably rightfully so. But an accident did not occur, we know what happened, yet we scold the pilots. On the non reporting of the incident, major issue. In some companys still, you are damned if you do an damned if you don't. I personnally would of reported it. If the company wants to sack me then so be it, at least I will be able to sleep at night.

[rammel]

The way QF has become, I'm not surprised it was not reported. In the past you used to be told that if you reported a mistake (you or someone else made) that that was the most important thing due to the safety of the flight. And importantly they wouldn't do anything against you, as you had done the right thing by reporting it.

I personally know of people involved in areas that do with the day to day operation, that have been sacked for reporting an error they made. One had an aircraft called back via the tower as it was at the holding point. It was an error that was more going to be an inconvienence to pax at the other end, but an error no less.

When we did the figures later the figures for the aircraft were not even 5% different. And the settings would have been the same.

Even in my role I made an error that went all the way through and was missed, but I reported it as soon as I noticed it. The only reason I didn't get hauled over the coals for it, was that the operating crew missed it on 3 different ocassions. It was covered up by them. No doubt for the same reason as this person was thinking. My error also related to fuel.

[Sunfish]

Are you alleging that Qantas culture no longer puts safety above all else?

[rammel]

No I'm not saying that. I'm saying that there seems to be a shift from the culture of "no blame" if you report something, to we have to find someone to blame.

[FlexibleResponse]

There are only two sorts of fuel tanks on aircraft:

1. Feed tanks.
2. Transfer tanks.

Feed tanks are tanks that can supply fuel to the engines.
Transfer tanks tanks are tanks that can supply fuel to the feed tanks.

It is the pilot's responsibility to ensure that there is sufficient fuel in the feed tanks to sustain engine operation throughout all stages of flight.

EVERYTHING else is secondary.

We are all human. But, let us all learn from the mistakes made by other pilots faced with the same responsibility outlined above.

[Iron Bar]

Capt Sherm is absolutely correct.

[amos2]

Capt sherm also has a rather strange attitude, methinks!

Never operated on "the slug" he says...and I presume he means the 737?

Flown 73s for 20 odd years, never heard the term slug in reference to them and would suggest no other 737 driver has either!

Having flown the 9 and the MD80 also, as he has, if what he says he believes is correct about the centre tank fuel not being available to the donks I would have to say"please explain"!

And if he's correct why would he rubbish the 737 that doesn't have that problem?

I suppose it goes without saying that he's an anti Airbus pilot also!

[pacific blues]

Do the centre tank pumps need to be switched off once all the fuel from that tank has been used?

[Captain Sherm]

Don't know about the 737 for that last question. On the 777 you get a prompt from the EICAS system and turn the pumps off. Scavenge pumps move the last couple of thousand to the mains when they are below 30,000 lb.

Amos....not anti-Airbus at all, except you have to say the 380 is dead ugly. All I was getting at was the remembrance that in 1974 when I first flew the 9, I realized along with many others in ground school that if you didn't get fuel out of the centre with AC pumps, you couldn't get it out. So if the engines flamed due to mismanagement you were dead meat.

As for the 737....it was a long time ago that I didn't fly it but I do recall it being called the slug. I know they were fun to pass in the 727-you could check out the hub caps

[galdian]

My only comment - due circumstances I now fly in an environment where the F/O's almost NEVER look at the overhead panels, ALWAYS concentrate on the two big shiny screens in front of them - the centre of their universe, in fairness the way they are trained to be. Sad, really.
In a previous life I was taught, and believe, to have a look around at everything every 15 minutes or so - can't hurt can it?
I am sure I probably do it more than I need to and the current F/O's are sitting there wondering... "why?"; well that's their f&*king problem as far as I'm concerned!

My point: as QF has a similar culture to my previous life how is it that, after 2.5+ hours of flight, apparently neither pilot has had a squiz, independently, maybe a few times, to see that everything "looks OK" and at some stage didn't twig that something "wasn't right?"

Standard procedures now so dominant that self preservation and pure common sense have to be considered negatives?? :ugh:

Cheers
PS: my current F/O's all wait for the "master caution" to come on before they have to turn them off (maybe fair enough); any thought of looking at those antiquated things from the past (fuel guages) and anticipating when it MAY happen (awareness??), no chance.
And comparing burn Vs fuel remaining - :ooh: - interesting concept!!

[Captain Sherm]

Very good point Galdian....in the "old days" the F/E would calculate the expected off Xfeed time and we'd all hold him to it....mostly very accurate...no special reason why it couldn't be an SOP to note the expected time to empty the centre tank....all that old "airmanship" stuff hasn't gone away....we can bring it back if we want

[haughtney1]

Having never operated the baby boeing, I'm probably the last person who can comment on the incident mentioned here.....I do have a question for the drivers however.
Is there any kind of configuration/low pressure warning when the centre tank pumps are off when there is more than a modest amount of fuel remaining?
As has been said, "there but for the grace of god....." so hopefully its a good reminder for all of us on here to be aware of our fuel position.

[Ron Jeremy Porn Star]

The 734 has three gauges plainly visible to both pilots...one could have expected either pilot to check the contents of all three gauges somewhere betweeen Perth and Swan Hill, probably a flight time of 2-3 hours.

[ScottyDoo]

"the slug" ...and I presume he means the 737.....never heard the term slug in reference to them and would suggest no other 737 driver has either!

He's talking about The Maggot, anos. The big, fat, slug-like Maggot. Spose you've never heard that one, either...???

You call yourself an airline pilot..???? :rolleyes:

Oh and what's wrong with rubbishing the airbus...... it's traditional to bag out a heap of sh!t, isn't it??

[Keg]

I thought the term maggot had it's genesis in the aftermath of '89? :confused:

I always assumed slug came from that.

[Flight Me]

And here I was thinking a slug had something to do with a piston.

[amos2]

Aw! Heck...I dunno why I keep putting up with you Cretins!

Anyways, Pacific, the answer to your question is yes.(why would you want to leave them on?)

For what it's worth I have flown the 734 with aux tanks and the pre start fuel call response used to be--- ****kgs ****Pumps On(4/6/8).

Called by the F/O and answered by the Capt (the only way in my opinion!)

And, I have also missed the centre pumps, wasn't picked up by my offsider and only picked it up during the climb doing a panel scan!

[Casper]

One can only wonder what has happened to the "old" philosophy of checking fuel quantity as displayed on tank gauges and compared against FMC quantity. Fuel Log? Not necessary in the modern cockpit? Fools ignore!

[Capt Basil Brush]

It seems they must have also missed the LOW fuel indicator when the main tanks get below 907kgs per side. The QRH will then suggest you find out why you have a LOW fuel indication.

[blueloo]

Just with the fuel log thing- a mijig - the 734/8 is a bit different vs other boeings I believe - the fuel log at QF is based on fuel burnt per engine as opposed to fuel remaining in tanks and FMC.

So you hit the little toggle - it shows on either the electro-mechanical gauges ( or screens on the 800 ) fuel used per donk - you then add up and compare to flight plan. So from this point of view - the fuel log isnt going to help you spot whether the correct pumps are on.

The other boeings you compare FMC calculated FUEL totaliser and whatever the other FMC calcd value is and compare to fuel remaining on flight plan. Not sure whether this would help you pick up which tanks are feeding the donks or not either.

So pretty much a careful scan preflight, or climb cruise etc is probably the way it will be picked up.


I too have missed the pumps early, but offsider has picked them up, or picked up in checklist. When I have missed them it is because the Captain has reached across and pressurised the hydraulics - which the F/O usually does and it is also the prompt for the F/O to turn the appropriate fuel pumps on.

I think this was mentioned as a factor in the report.


Capt Basil - the 734 has crappy LCD gauges on Captains side which are poorly illuminated. I dont believe there is a low fuel warning as per the 800.

[Capt Claret]

FWIW, in a Douglas Boeing, the EAD will throw up an alert if:
Fuel other than ballast fuel is in the centre tanks and the centre tank pumps are not selected on, with an engine/s running.
Fuel pumps for a main tank not selected on and engine/s running.
Ballast fuel level is less than that entered into the FMS and engine/s running.

Clever planes Douglas Boeings. :}

[aerostatic]

This incident highlight at least a couple of issues.
One is the procedural one of the checklist response - now carried out in accordance to 'area of responsibility'. Back in the good old days (with the 737 at any rate) on the ground the checklist used to read by the fo and responded to by the captain. This meant that the person with the ultimate responsibility for the operation was required to verify the correct state when not preoccupied with flying or taxiing the plane. Not full proof but arguably a better system.
The other issue is mixed fleet flying, when I say that I mean NG and classic which are actually quite different machines, albeit with the switches in more or less the same place. In the case of QF the vast majority of their 737's are now the NG. The NG has lots of nice little features - it tells you if you miss the transition altitude/level (display changes colour), it gives a config warning if the centre tank pumps are left off when they should be on and finally there is a low fuel warning if a main tank fuel quantity drops below 2000 lbs (907 kg). The classic has none of the above features. The problem with the mixed flying of the classic and the NG is that a pilot's mind becomes dumbed down because of all the nice 'backups' on the modern flight deck. The scene is then set for an error to go undetected when flying the less modern machine because the nice backup features are not there and the pilot's mind is less tuned to picking them up.
And now I too have to confess to having made this same error, albeit I detected it shortly after reaching top of climb when I noticed the main tank fuel quantities had reduced whilst and there was lots of fuel sitting in the centre tank - woops - but at least the error was detected and the corrected in a reasonably timely manner. I suspect this error is reasonably common on the classic, but almost always detected before an undesired aircraft state results.

[baylover]

Guy's.
I'll stick to the point.
The incident is unfortunate, and I know one of the crew members personally.
He is genuinely a really nice person, and whilst nobody can support his actions I think the company, "Qf ",have made the appropiate response.
To further berate this person on a public forum based on rumors from here is demeaning.
Qf have dealt with this matter internally and that is where it should stay.

[Bundy Bear]

Baylover,

In defense of everyone who has posted on this thread, I don't believe that there has been any berating of the person's involved in this incident.

There seems to be a healthy discussion regarding everyone interested in the details and how we can all learn from this. This stuff can happen to any of us, or can nearly happen to any of us. Learning from this info can only make us all think about it.

:cool:

[maggot]

amos;
For what it's worth I have flown the 734 with aux tanks and the pre start fuel call response used to be--- ****kgs ****Pumps On(4/6/8).
when we changed over to our current 'normal procedures' our chklst item became "Fuel ____kgs, pumps ON."
I, and it seems many others, got into the habit of saying "9000kgs, 6 pumps ON" I thought it made sense due to the many & confusing centre fuel pump config requirements across the fleet 300?/400/800. However, not long after the procedures being bedded down, they were reviewed - by audit? I can't remember - but someone in an official capacity, via standing order or memo, gave us the official interpretation. I big list of stuff that was happening on line that was not 'exactly' how it was intended to be. On that list was the fuel item response.

[kiwi chick]

Yeah, I don't think anyone has berated the Pilot either?

All I have to say is:

Ooooooops. And double ooooops. :eek:

[sayallafter]

It would be interesting to know Boeing’s philosophy for changing the checklist to be just “__KG/LBS, PUMPS ON.

Considering that when completing a set up, in all likelihood, you will only have fuel in the mains and thus at most only four pumps on.

If it was forgotten to put the centre pumps after the centre fuel load has been added,at a response to the checklist call of FUEL …..” X KG, FOUR PUMPS ON” gives the chance of a correction.

Plain old “…..PUMPS ON” doesn’t really mean much as there will be times when you only need four pumps and then there will be times when you need six.