FLC OF AN MLG HAS AN ACFT AND GATE CHANGE WHICH IS NOT AS ORIGINALLY ASSIGNED. DURING PREFLT THEY MISREAD THE FUEL GAUGES AND TKOF WITH INSUFFICIENT FUEL.

Date: 1998-08 · Aircraft: Commercial Fixed Wing

Anomalies: aircraft-equipment-problem-critical|other-unspecified

Synopsis

FLC OF AN MLG HAS AN ACFT AND GATE CHANGE WHICH IS NOT AS ORIGINALLY ASSIGNED. DURING PREFLT THEY MISREAD THE FUEL GAUGES AND TKOF WITH INSUFFICIENT FUEL.

Narrative

FLC ARRIVED IN ATL AT XX05 LCL WITH A SCHEDULED DEP OF XX50 LCL TO CAK. IN RANGE TO ATL THE CREW HAD BEEN ADVISED BY OPS THAT THE ACFT WE WERE IN WOULD TURN AND GO TO CAK. ON AND IN TIMES WERE PASSED TO OPS ON ARR WITH NO INDICATION OF AN ACFT CHANGE. POSTFLT CHKLIST WAS COMPLETED. WE HAD NO MAINT WRITE-UPS SO I PROCEEDED TO GET THE FO AND MYSELF SOMETHING TO EAT SINCE WE HAD CHKED IN VERY EARLY. UPON ARRIVING BACK; THE FLT ATTENDANT ADVISED ME THAT WE HAD JUST RECEIVED A LAST MIN ACFT SWAP FROM DISPATCH. THE FO AND MYSELF PACKED UP OUR FLT BAGS FOR THE HIKE DOWN TO OUR NEW DEP GATE FOR A NEW ACFT PREFLT AND WT AND BAL. DEP DISPATCH PAPERS WERE REVIEWED AND I SIGNED FOR 23000 LBS OF FUEL. THE MANUAL WT AND BAL WAS STARTED; THEN THE BEFORE START ENG CHKLIST WAS READ BY FO AND ANSWERED BY ME. WHEN WE GOT TO THE ITEM ON FUEL QUANTITY ON THE CHKLIST I LOOKED AT THE GAUGES; ADDED 9+9 IN WING TANKS = 18 PLUS 5.4 IN CTR = 23400. WE BOTH MADE A COMMENT TO THE FACT THAT WE HAD 400 LBS OVER REQUIRED DISPATCH FUEL. ON ENG START WE LOOKED AT THE GAUGES AGAIN AND CAME UP WITH 23400 LBS. NORMAL ENG START FOLLOWED THE COMPLETION OF THE MANUAL WT AND BAL AND GATE DEP NOTED AS XY00. WITH NO ONE IN FRONT OF US ON TAXI OUT WE WERE AIRBORNE AT XY10. FO WAS FLYING AND AT 4000 FT IN PREPARATION FOR THE CLB CHKLIST; KNOWING I HAD CTR TANK FUEL; REACHED UP TO TURN THE PUMP SWITCH ON; ONLY TO SEE NO FUEL IN CTR TANK -- ZERO. FURTHER SCAN ONLY SHOWED 5000 LBS IN EACH WING TANK. WE DIDN'T INDICATE ANY FUEL ABNORMAL. WE DID HAVE ERRATIC PRESSURIZATION CTL. I IMMEDIATELY PICKED UP THE MIKE AND ADVISED DEP THAT WE NEEDED TO RETURN AND LAND BACK IN ATL. WITH NO ONE ELSE IN THE PATTERN WE WERE AGAIN ON THE GND IN LESS THAN 10 MINS. DURING TAXI BACK IN; STILL IN A STATE OF DISBELIEF; I BEGAN TO TRY TO ANALYZE WHAT HAD OCCURRED. WE BOTH HAD LOOKED AT THE FUEL GAUGES AND THOUGHT IN OUR MIND'S EYE THAT WE WERE LOOKING AT CTR TANK FUEL WHEN IN FACT WE MUST HAVE BEEN LOOKING AT THE WING GAUGE. IT WAS READING 5400 LBS. WE SAW WHAT WE WANTED TO SEE 9+9 = 18 + 5.4 = 23400 LBS. I CAN ONLY SAY THAT FATIGUE; INSIDIOUS AS IT IS; HAD CONTRIBUTED TO THIS INCIDENT. I HAD FLOWN FOR 9 DAYS IN A ROW WITH A CONTINUOUS DUTY OVERNIGHT TRIP. 3 MONTHS OF 100 HR FLYING HAD ALSO CONTRIBUTED TO MY STATE OF STRESS. MANUAL WT AND BAL HAD JUST BEEN REINTRODUCED TO OUR COCKPIT WORKLOAD 3 DAYS PRIOR. A SUGGESTION HAS BEEN PASSED TO MGMNT BY ME THAT PERHAPS THE FUELERS COULD GIVE THE COCKPIT CREW A FUEL SLIP THAT WOULD AT LEAST INDICATE THAT A FUELER HAD IN FACT VISITED THE ACFT. IT WAS ALSO SUGGESTED THAT DISPATCH/MAINT REFRAIN FROM VERY LAST MIN ACFT SWAPS WHENEVER POSSIBLE. FATIGUE; LAST MIN CHANGES; WORKLOAD AND A DESIRE TO GET THE JOB DONE ALL CONTRIBUTED TO THIS INCIDENT.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.