MDT CREW TAKE OFF WITH INSUFFICIENT FUEL.

Date: 1999-07 · Aircraft: Medium Transport; High Wing; 2 Turboprop Eng · Phase: ground

Anomalies: deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy

Synopsis

MDT CREW TAKE OFF WITH INSUFFICIENT FUEL.

Narrative

I WAS THE FO ON A PART 121 FLT FROM JFK TO BOS. AT THE COMPLETION OF THIS FLT; THE CREW DISCOVERED THAT THE FLT WAS INITIATED WITHOUT ENOUGH FUEL AS REQUIRED BY REGS AND COMPANY OP SPECS. THE CAUSE OF THIS PROB WAS INEFFECTIVE CRM. THESE ARE THE EVENTS LEADING UP TO THE PROB. AS FO; I WAS FIRST IN THE COCKPIT. I BROUGHT THE RELEASE PAPERWORK WITH ME TO THE AIRPLANE AND INITIATED A PREFLT; AND A BEFORE START CHK 'FLOW.' DURING MY BEFORE START FLOW; I REALIZED THAT THE ACFT HAD NOT YET BEEN FUELED. THE RELEASE PAPERWORK CALLED FOR AROUND 3100 LBS. WE HAD AROUND 2500 LBS. I CALLED OPS AND REQUESTED A FUEL TRUCK; THEN CONTINUED WITH PREFLT DUTIES. SHORTLY AFTERWARDS; THE CAPT ARRIVED. BECAUSE THE CABIN WAS HOT; HE IMMEDIATELY STARTED ENG #2 (AFTER RECEIVING CLRNC FROM RAMP PERSONNEL). HE DID NOT REQUEST; NOR DID I PROMPT HIM FOR A BEFORE START CHKLIST. HE WAS IN QUITE A HURRY BECAUSE OUR FLT WAS LATE; AND I WAS BUSY WITH OTHER DUTIES. AS WE WERE TAXIING; WE ACCOMPLISHED AN OBLIGATORY BEFORE START; FOLLOWED BY THE AFTER START CHKLIST. THESE CHKLISTS WERE RUSHED; AND I ALLOWED THEM TO BE DONE IN A HURRIED FASHION. BECAUSE OF THE 'HURRY AND GO' ATMOSPHERE; I COMPLETELY FORGOT ABOUT OUR FUEL; AND IT WAS NOT PROPERLY CHKED DURING OUR BEFORE START CHKLIST READING. ONCE OUT OF THE GATE; WE PERFORMED THE REST OF OUR DUTIES SATISFACTORILY AND LANDED IN BOSTON WITHOUT INCIDENT. AS WE TAXIED TO OUR GATE WE RECEIVED A LOW FUEL WARNING. THIS WARNING OCCURS WHEN THE FUEL LEVEL IN EITHER TANK REACHES AROUND 350 LBS. UPON INSPECTING OUR FUEL QUANTITY GAUGES; WE DISCOVERED APPROX 550 LBS IN THE L TANK; AND APPROX 480 LBS IN THE R TANK. THE FUEL LOW LEVEL WARNING HAD OCCURRED EARLY; PROBABLY DUE TO FUEL SLOSHING DURING TAXI. HOWEVER; WE HAD LANDED WITH ONLY AROUND 1100 LBS OF FUEL; ENOUGH FOR AROUND 40 MINS OF FLT TIME. UPON FURTHER INSPECTION; WE DISCOVERED WE HAD TAKEN OFF WITH ONLY ABOUT 2300 LBS OF FUEL. OUR RELEASE CALLED FOR A MINIMUM OF BTWN 2500-2600 LBS. HAD CIRCUMSTANCES BEEN DIFFERENT DURING OUR FLT (IE; BAD WX; HVY TFC; ETC); THE OUTCOME OF THIS VERY FOOLISH MISTAKE COULD HAVE BEEN CATASTROPHIC. THE BLAME FOR THIS ERROR RESTS SOLELY ON THE FLC. THE VERY FIRST STEP IN THIS INCIDENT OCCURRED WHEN THE CAPT TRIED TO HURRY THINGS ALONG. HIS ENG START; AND BEFORE START CHKLIST WERE OUT OF ORDER. (THIS IS A COMMON PRACTICE AMONG MANY CAPTS WHEN THE WX IS HOT. THE FIRST PRIORITY BECOMES TO COOL THE CABIN. IT IS ALSO AGAINST COMPANY POLICY.) IT IS MY OPINION; HOWEVER; THAT THE BULK OF THE BLAME RESTS ON MYSELF AS THE FO. MY JOB IS TO BACK UP AND SUPPLEMENT THE CAPT. IF HE ERRS; I SHOULD CATCH HIS ERROR AND CORRECT IT. IF HE FAILS TO PERFORM PROCS PROPERLY; IT IS MY JOB TO STOP HIM AND ENSURE THAT PROCS ARE FOLLOWED. I OBVIOUSLY DID NOT PERFORM MY DUTIES SATISFACTORILY. THIS MISTAKE HAS CAUSED ME MUCH ANXIETY. I DID NOT REALIZE I WOULD EVER MAKE SUCH A BASIC; EASILY AVOIDED MISTAKE. I HAVE SPENT MUCH TIME EXAMINING MYSELF AND QUESTIONING WHY I ALLOWED THIS TO HAPPEN. I HAVE IDENTED 4 FACTORS THAT CONTRIBUTED TO THIS MISTAKE. FIRST OF ALL; I WAS NEW TO THE OP AT KENNEDY ARPT. I AM BASED IN MIAMI; FL. I HAD BEEN SENT TO KENNEDY AS A TEMPORARY DUTY ASSIGNMENT BEGINNING ON JUL/XA/99. THE DAY OF THE INCIDENT WAS MY SECOND DAY OF FLYING OUT OF JFK. BECAUSE OF MY INEXPERIENCE; I RELIED HEAVILY ON THE CAPT AS I GREW ACCUSTOMED TO THE NEW ENVIRONMENT. I ALLOWED THE CAPT TO DO THINGS HIS WAY UNTIL I FELT COMPETENT ENOUGH TO CHALLENGE HIM. SECONDLY; I WAS TIRED. IT WAS THE LAST FLT OF THE DAY. I BELIEVE FATIGUE PARTIALLY CAUSED ME TO FORGET TO RECHK THE FUEL; EVEN AFTER I HAD NOTICED IT EARLIER. HAD I EVEN REMEMBERED THAT WE INITIALLY DID NOT HAVE THE NECESSARY FUEL; WE WOULD NEVER HAVE LEFT THE GATE. HOWEVER; THE THOUGHT OF OUR FUEL LOAD NEVER CROSSED MY MIND AGAIN UNTIL WE LANDED IN BOS AND GOT THE ALERT. THIRDLY; I HAD EXTRANEOUS CONCERNS CLUTTERING MY MIND. THERE WERE SEVERAL DISTRACTIONS I HAD ON MY MIND PRECEDING THIS FLT. I BELIEVE THESE CONTRIBUTEDTO MY LACK OF AWARENESS. LASTLY; I REALIZED THAT I HAVE NOT BEEN STRONG ENOUGH AS AN FO IN SEEING THAT MY CAPTS ALWAYS FOLLOW PROC. I BELIEVE MY LACK OF 'BACKBONE' WAS A MAJOR FACTOR IN THIS INCIDENT. HAD I INSISTED THAT WE CAREFULLY FOLLOW THE CHKLISTS; THIS MISTAKE WOULD HAVE BEEN CAUGHT BEFORE WE EVEN STARTED THE ENG. IN CONCLUSION; THIS MISTAKE OCCURRED BECAUSE THE CREW MEMBERS WERE IN TOO BIG OF A HURRY. THERE WAS NO INTENTIONAL DISREGARD FOR REGS. WE JUST WERE GOING TOO FAST. WE WERE FORTUNATE THE CONSEQUENCES WERE NOT MORE SERIOUS.

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