ENG FAILURE OVER THE PACIFIC WHEN FUEL IS MANAGED IMPROPERLY ON A DC10-40.

Date: 2000-03 · Aircraft: DC-10 40 · Phase: cruise

Anomalies: aircraft-equipment-problem-critical|deviation-altitude-excursion-from-assigned-altitude|deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|other-eng-fuel-starvation

Synopsis

ENG FAILURE OVER THE PACIFIC WHEN FUEL IS MANAGED IMPROPERLY ON A DC10-40.

Narrative

1 HR AFTER TKOF; LEVEL FL350; BTWN ZURIC AND ZAALE ON A331; ENG #2 FLAMED OUT DUE TO FUEL STARVATION. WE TURNED L TO CLR THE AIRWAY AND DSNDED TO FL300 WHERE A NORMAL AIRSTART WAS ACCOMPLISHED. WE RETURNED TO FL350 AND REJOINED A331; SFO COMMERCIAL RADIO WAS ADVISED OF EVERYTHING AND EVERYTHING WAS DONE WITH THEIR AND OAKLAND OCEANIC'S KNOWLEDGE. SUPPLEMENTAL INFO FROM ACN 466651: 2 ABNORMALITIES EXISTED IN THE FUEL SYS: 1) ACFT DISPATCHED WITH AN MEL FOR #2 MAIN TANK FILL VALVE INOP. PROC INCLUDED DIRECTION TO XFEED FUEL IN ORDER TO MAINTAIN BAL (IN LIEU OF NORMAL FUEL XFER). 2) FUEL FILL VALVES ON OPERATIVE TANKS #1 AND #3 FAILED TO AUTO-SHUT OFF AT NORMAL POINT DURING ROUTINE FUEL XFER; RENDERING #2 TANK LEVEL SOMEWHAT LESS THAN #1 AND #3 (A PREVIOUSLY UNKNOWN MALFUNCTION). IN ACCORDANCE WITH MEL; CORRECTIVE ACTION WAS XFEED OF FUEL FROM TANKS #1 AND #3 TO ALL 3 ENGS; WHILE CEASING FUEL FEED FROM TANK #2 TO ENG #2. SMALL FLASHLIGHT WAS PLACED ON #2 TANK FUEL SWITCH GUARD (WITH SWITCHES OFF) AS A REMINDER OF XFEED IN PROGRESS. WHEN ALL TANK LEVELS WERE BALANCED; I PROCEEDED TO END THE FUEL XFEED. MY INTENTION WAS TO LIFT THE FLASHLIGHT OFF THE SWITCH GUARD AND TURN ON 2 FUEL PUMPS TO REESTABLISH PRESSURE/FUEL FEED FROM #2 TANK TO #2 ENGINE. I FAILED TO TURN THE SWITCHES ON. THE NEXT STEP WAS TO CLOSE THE #2 XFEED VALVE. DUE TO LACK OF POSITIVE FUEL PRESSURE; THE #2 ENG IMMEDIATELY FLAMED OUT. FATIGUE (IT WAS ABOUT XA00 'BODY TIME') AND A POSSIBLE DISTR LIKELY CONTRIBUTED TO MY FAILURE TO OPERATE THE FUEL SYS AS I INTENDED. I BELIEVE ANY COCKPIT ACTION THAT COULD AFFECT ENG OP SHOULD BE OBSERVED/CONFIRMED BY A SECOND CREW MEMBER. MY POLICY IN THE FUTURE WILL BE TO SOLICIT 'OBSERVATION' FROM THE CAPT; AND MUTUAL AGREEMENT PRIOR TO INITIATING OR CEASING ENG #2 XFEEDS.

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