Qantas flight low on fuel, reserves switched off

[beamender99]

"....investigators found a 737 flying over Victoria appeared to be low on fuel before the pilot realised reserve fuel pump switches were off.
The bungle, which occurred on August 11 when the airliner was en route from Perth to Sydney, saw the Australian Transport Safety Bureau classify the fuel scare as a "serious incident", which remains under investigation.

An October 11 ATSB report on the fuel bungle stated: "The main fuel tanks were low on fuel and the investigation estimated there was about 100kg in each.
"The pilot in command observed 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 centre fuel tank held a reserve of 4700kg.
The crew discussed the problem and confirmed the reserves would get the aircraft safely to Sydney.
The 737-476, able to carry up to 150 passengers, was 50km northwest of Swan Hill - almost three hours into its flight - when the error was identified.
Qantas chief pilot Capt Chris Manning said the incident was taken "extremely seriously".

Mods please delete if this is old old news. It is todays newspaper.

[Seven Seas]

Sounds nasty!

5 minutes from disaster. Had the mains run dry, there would have been no fuel for the APU and no way of powereing the pumps for the centre tank.

[aflyer100]

Don't we use the centre tank first in the 37? This one was a slightly later model but I remember learning how the center pumps put out slightly more pressure to ensure the center tank was used first.

[BOAC]

Were they asleep? Several pointers/alerts missed.:eek: I wonder what alerted them at all? Did the cabin crew say 'What's them yellow thingies on the dashboard"?

This may have been on D&G but not here, I think. Just a touch of adverse press at the moment for QANTAS?

[PAXboy]

beamender99occurred on August 11
Any idea which year that was???

Sounds like the press are raking the archives for anything on a particular carrier, just to sell more papers = SOP.

[Capt Kremin]

It was a year ago. Paxboy is right.

[Bruce Wayne]

11 Aug 2007 - VH-TJE

[keel beam]

"Sounds like the press are raking the archives for anything on a particular carrier, just to sell more papers = SOP"

Takes the pressure off BA :}

[Capt Claret]

If the crew concerned were the first ever to do such a thing (omit to burn fuel from centre/aux tanks first) I'll walk starkers, backwards, down Bourke Street! :}

[Oxidant]

If the crew concerned were the first ever to do such a thing (omit to burn fuel from centre/aux tanks first) I'll walk starkers, backwards, down Bourke Street!

Bit chilly at the mo. How about waiting for the summer?;)

[Kiwiconehead]

Sounds like the press are raking the archives for anything on a particular carrier, just to sell more papers = SOP.

Qantas lost a Connie in 1960 - shhhh - don't tell the press.

[TWT]

Funny,the press don't seem too concerned about trains that carry a lot more passengers at high speed all over the world.Imagine if every incident that happened had to be reported in as much detail as that required for passenger aircraft :uhoh:

[cortilla]

would love to know what a reserve fuel pump switch in a 737 classic is. Granted i've only been flying em for 6 months, but i'm sure that would have been covered in groundschool somewhere.

[Oxidant]

The original post has a mixed grasp of the 737.Both phrases, "centre tank" & "reserve tank" are used, in this case they meant “centre”
However, some 737 "classics" were fitted with a Rogerson aux fuel tank. So you had an extra panel with the aux tank swiches & low pressure lights. Plus a Smiths or Simmonds Aux tank indicator.

"Sometimes is is better to remain quiet & seem a fool, rather than open your mouth & remove all doubt";)

[Romeo India Xray]

Supposing this was an AC fitted with the 4th aux tank, can you tell me how the 4th indicator was displayed? I have never flown a 4 tank 73 but remember reading somewhere that the 3 indicator triangle became a square - If this is the case then neither intuitive or ergnomic in design, and real potential for error.

However if this was the 3 tank varient then down to 100kg IS a bit "running on fumes" :eek:

[Oxidant]

Sorry I don't know how to add a pic.
There are three combinations;
1. The normal three in the "pyramid" + the aux somewhere underneath.
2. The square as you mention.
3. A sort of diamond, with the wing tanks "West & East" & the centre & Aux. "North & South"

Cheers.

[Cool banana]

A couple of QF B737-400 did have Aux tanks but have been since the arrival of the B737-800 the Aux tanks have all been removed from classic fleet.
The Qf 737 classic only has 3 mains fuel tanks (not including the surge tanks), Left/Right wing and center tanks.

[Jonny Suave Trousers]

lol, gee perhaps SLF buy the papers that the press produce?

Perhaps they are interested?

[Romeo India Xray]

Thanks for that - I had only read about the square - the others you describe seem to be much more intuitive. :ok:

[RAD_ALT_ALIVE]

Yes, well perhaps that's true. But a little balance would be nice.

This morning, the biggest selling paper in Melbourne (Herald Sun) had an article about a Qantas flight being cancelled because of a maintenance issue that was unable to be rectified in time!!

Prior to the Manila diversion, this would NEVER have seen the light of day. It is now obviously nothing more than Qantas-bashing. I'm sure it happens throughout the world when a carrier has an incident, but it's pretty distasteful all the same.

[Evening Star]

Funny,the press don't seem too concerned about trains that carry a lot more passengers at high speed all over the world.Imagine if every incident that happened had to be reported in as much detail as that required for passenger aircraft :uhoh:

ES Minor drives trains for a living and has 'views' on this exact point. In summary, the media do not do any better in reporting train incidents.

(Nor do they do any better in my field of expertise. Mrs ES accuses me of shouting at the idiots on the telly every time there is a report of flooding/drought/whatever watery. Bottom line, load of people with humanities degrees and an ego have to report something about a subject for which they have no prior knowledge to a deadline that sells. What can one expect?:yuk:)

Sorry, for the thread drift, but I do feel better for the rant...

[Basil-Fawlty]

Few facts, :confused:
BOAC (http://www.pprune.org/forums/members/14135-boac)
" Did the cabin crew say 'What's them yellow thingies on the dashboard"?":}
The low pressure lights for the MAIN Tanks' boost pumps will come on if the boost pump pressure is low and the pump switch is ON. For the boost pumps in the No. 1 tank and No. 2 tank, the low pressure lights will come on if the boost pump switch is OFF. For the boost pumps in the centre tank, the low pressure lights are off if the boost pump switch is OFF. Thus, no low pressure lights are on during the usual part of the flight.


The pilot will not be able to operate the elec Hyd pump for long as the HEX need a minimum of 750KG in the main tank.

The Aux tank do not feed directly to the engine. The engine fuel feed system will supply fuel to the engines by a direct tank-to-engine feed or from any tank to either or both engines through the crossfeed valve when the boost pumps are operating.

aflyer100 (http://www.pprune.org/forums/members/214362-aflyer100) " Don't we use the centre tank first in the 37?":uhoh:
You are right, you do use the centre tank first but you have to have the centre pump switches ON. When the switches are on during the flight, the centre tank will feed first any way. This is due to The centre tank boost pumps override tanks No. 1 and 2 boost pumps since pressure from tanks No. 1 and 2 tank boost pumps has to overcome a boost pump check valve cracking pressure.
All aircraft with O/R booster operate with the same principle.i.e B767,B747 etc.
short flight do not require centre tank fuel uplift. Perth to Sydney is a different story.

But then again what do I know about B737 fuel system I am just a hotel owner in Torquay¨!:cool:

Safe and happy flying to all from Cybil, poly and Manuel.



BF:ok:

[BOAC]

Few (corrected) facts, 1) There would be 2 yellow 'thingies' on the dashboard that say 'LOW' (I don't think Boeing have a warning for 'effin low':))
2) The 750kg is a limit for elec pump ground ops only (ok, they could have been there PDQ:))
3) Not sure about whether your 'AUX' tank comment was for me?

Better luck with the hotel:) How's Manuel?

I wonder if they were actually 'juggling' the centre/wings contents to avoid fuelfrost icing and FORGOT........!?:eek: Damn these difficult crosswords.

[Lookleft]

BOAC-One thing you don't have to worry about in Oz is the low tepmperature of your fuel. They simply didn't put the CWT pumps on during the pre-flight.

[llondel]

lol, gee perhaps SLF buy the papers that the press produce?

No, I can't remember the last time I paid for a newspaper.

[Basil-Fawlty]

BOAC

"There would be 2 yellow 'thingies' on the dashboard that say 'LOW' ".

You are right but you have to have the CTR Booster switches to be ON to get the yellow "Thingies" if the switches are off "According to the artical) you will not see any thingies yellow or red! No fuel will be going any where for start.
The 750 KG is for cooling purpose only In case the Hyd pump need operating. just a remarks no more no less.

The Aux tank was not for you!

Thank you for your best wishes BOAC, the hotel bussiness is better than the aviation bussines for sure, at least you do not have pay for any fuel sucharge or airport tax, Just a very good hospitality from Cybil, poly and manuel... Oh and me.
Safe and happy flying to all:ok:
BF

[BOAC]

To avoid confusing the masses:

Lookleft - it is cruise TAT/time/humidity that decides whether you get fuelfrost icing and being in Oz makes no difference. Per-Syd would easily have been enough.

Basil - the 'LOW' warnings have nothing to do with the pumps! You are confusing these with 'LOW PRESSURE'. Of course, there would also have been a 'CONFIG' warning there. That's 3 yellows they missed, plus a few checks.......................

Did they finish the crossword? With 4700 in ctre and having used 7600, I guess they were close to Syd and tanking?

[fc101]

TWT wrote:

Funny,the press don't seem too concerned about trains that carry a lot more passengers at high speed all over the world.Imagine if every incident that happened had to be reported in as much detail as that required for passenger aircraft

They do except its more along the lines of :

"Train failed to swerve out of way of the innocent [sic.] driver who crashed through the barriers and failed to notice the red flashing lights."

Now how many killed every day in car accidents....

[bobbobbob]

It was a 737-400 so no LOW or CONFIG warnings

[BOAC]

bbbbb - whoops! Missed that completely! Didn't expect them to be using CL 737. Apologies. Just leaves the crossword, then:)

[Ignition Override]

An MD-80/DC-9 crew missed these many years ago in their 'climb checklist'.
It got really quiet for a while over the high desert.

Due to fuel sloshing in the right main fuel tank, the APU started and with normal AC (and DC power), the center fuel pumps (for about 6,000 lbs. of fuel) then had power to operate, after they had already been switched on.

Just two extra glances at the gauges and pumps (and cabin climb rate etc) by the 'Flying Pilot', after the normal time to review the checklist at 10,000', can prevent this. Also, a center fuel pump's popped circuit breaker once left us in a similar situation, but after about 2,000 lbs had burned off, and then the abnormal pump procedure solved the problem.
PFNEP, PNEP (Not-eating peanuts), PPMD, PNPMD (Pilot NOT-Pouring Mountain Dew), PNEFC (Pilot Not eating fish And chips), NEFP, flying Non-eating pilot., Eating Non-flying pilot..it does not matter who takes some extra glances. Even a jumpseating pilot.
Aren't the results what count?

[Magnet77]

Having personally flown all B-737 series from the -100 through the NG -800 for 16 years I have a good feel for probably what happened here. While I hasten to add that I have been out of the 737 series flying for over five years now, I nevertheless recall a few of the got-chas on the aircraft and strategies used to mitigate same with fuel. Since the aircraft was a classic aircraft (737-400), I will leave the NG (-800) stuff mostly out, but it is a factor as all Qantas 737 crews fly both -400 and -800 virtually every day they fly more than one sector which is most days.



1)The first exposure for the flight crew to the fuel system is during preflight of the overhead panel when the Captain verifies that the fuel in tanks was what was ordered preflight by referring to the numbers (usually written on his hand ;>). Then on the fuel panel, (in my day the Captain, but now) the F/O would select all boost pumps on (wings and center pumps – six in total) just prior to engine start. To my knowledge, Qantas aircraft did not have aux tanks operating in their 737 fleet in 2007. Also a couple of years ago Qantas procedures aligned with Boeing procedures changing areas of responsibility from the Captain to the F/O on the fuel panel before starting (As I recall it but I could be wrong here). Added to this, Boeing issued an AD that says to leave the fuel boost pumps off until just before starting the engines. This is a mitigating factor as in the past, all boost pumps were placed on when the fuel was correct in tanks. That Boeing AD, no doubt issued for a good reason, nevertheless, set this situation up to happen.

There is an exception to all boost pumps-on which is when there is no fuel in the centre tank, or less than 453 kg of fuel in the centre tank in the classic 737(-300-400). In this latter case the centre pump switches are left off. With 4700 kgs. in the center tank, this was the first missed opportunity by the F/O (monitored by the Captain) to turn the centre tank pumps on. Qantas procedures have changed making the preflight fuel panel an area of responsibility of the F/O, however, both are responsible for the fuel.

On the NG -800, fuel pumps are left off by Boeing procedure for less than 2300 kgs. in the centre tank until after takeoff. As you can see, there are several different procedures relating to fuel boost pumps with differing amounts of fuel on each of the -400 and NG -800. In most cases on most sectors, the centre tanks are in fact procedurally left off for takeoff. That was not the case for 4700 kgs in the centre tank on this sector. The centre tank pumps should have been selected on by the F/O before starting the engines.

2) During the reading of the Before Start Check lists, when it came to “Fuel”, the Captain would announce the fuel in tanks “12,300 kgs. and Pumps-On”. When I flew the 737, the response was "12,300 kgs and x pumps-on and we ordered 12,300". There was a clear cross check of the fuel quantity and fuel pumps selected on. Procedures changed and the pumps were missed. This was the second missed opportunity by the Captain, and by the F/O who was to place the fuel pumps on according to procedures and then read the check list. The F/O should also have verified that the responses were correct on the fuel panel from the Captain in agreement with the checklist and the aircraft configuration for the sector. Both the Captain and F/O missed the centre tank pumps off.


3) After take off and accelerating to climb speed was the first time airborne to check the fuel state and pumps on/off, particularly if you had intentionally left the pumps off prior to takeoff (see para. 1 above). The error could have been caught at this early stage but it was not.


4) After level off, there should have been a scan of the aircraft systems and automation to ensure that all is well. This was the best time to have caught the fact that the fuel pumps had been left off during preflight.



5) It was correctly pointed out earlier in this thread that with the center boost pumps off, the caution lights would have been off as well. Only seeing the switches in the off position and/or noticing the dwindling fuel content in the wing tanks while the centre tank quantity remained unchanged would tip off the crew that the centre pumps were selected off. The fuel caution lights only appear when one or both pumps are selected on and one or both pumps develop low pump output pressure (not low fuel quantity). In the -400 there are no other electronic warnings associated with low fuel in the wing tanks irrespective of the content of the centre tank. This was corrected in the NG series by Boeing.


6) To the crew’s credit, they did catch the error but it could have been even more embarrassing for them and Qantas if one or both of the engines had flamed out before the discovery of their oversight.

7) This incident was set up by the Boeing AD and pre-departure procedure changes in my opinion. In addition this was one crew's error on one sector on one day. It’s that simple. With thousands of considerations on every sector to deal with, stuff happens, pilots some times make mistakes, but hopefully, strategies are put into place over one’s career to mitigate such occurrences earlier, rather than later and certainly before its too late. Over the thousands of hours flown in a career we all have horror stories due to our own oversights or distractions. If you haven’t, then either you're not being honest with yourself or you just haven’t been flying very long. Pilots are humans and humans err. CRM and a host of procedures are designed to mitigate such errors from becoming incidents.

8) In this case, Boeing put a hole in the 'Swiss Cheese Model' with a fuel boost pump AD to leave the fuel pumps off to the last minute before the checklist, and changed procedures that changed the fuel panel from the Captain to the F/O. Like most incidents in aviation, there is almost never a single cause. In this case I firmly believe that the cause should be shared between the Boeing AD notice to leave fuel pumps off until starting engines, pre-start procedures and with the pilots error on the day. It is not all the pilots' fault. I am not bashing anyone here.



9) Its too simple to say that crossword puzzles were being done or newspapers being read without knowing the facts, tongue-in-cheek or otherwise. Obviously these sorts of things were not being done at every point mentioned above when the threat could have been discovered and corrected negating a potentially dangerous situation. Pilot error can have many causes.


10) Nevertheless, my 41 years of flying tells me that there was more involved in this incident than just what was on the surface of it. Knowing a little about Qantas and its reputation, the pilots involved would have been dealt with fairly but firmly after this incident and procedures put into place or existing ones reinforced to hopefully prevent it happening again. Nothing is ever procedurally perfect nor pilot-proof as we all know too well. Having said that, aviation is our business and we love it (or most of us do).


Others may have differing views and they are entitled to them. Best regards, Magnet77