From SKYbrary Wiki
| Summary
|
| On 11 August 2007, a Qantas Boeing 737-400 on a scheduled passenger service from Perth, WA to Sydney, NSW was about three quarters of the way there in day VMC when the master caution light illuminated associated with low output pressure of both main tank fuel pumps. The flight crew then 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 flight was completed without further event.
|
|
|
| Event Details
|
| When
|
August 2007
|
| Event Type
|
HF, LOC
|
| Day/Night
|
Day
|
| Flight Conditions
|
VMC
|
| Location
|
| Approx.
|
near Mildura City, Australia
|
|
Loading map...
|
| General
|
| Tag(s)
|
Event reporting non compliant
Inadequate Aircraft Operator Procedures
|
| HF
|
| Tag(s)
|
Fatigue
Ineffective Monitoring
Pilot Medical Fitness
Procedural non compliance
Stress
|
| LOC
|
| Tag(s)
|
Flight Management Error
|
| Outcome
|
| Damage or injury
|
No
|
| Causal Factor Group(s)
|
| Group(s)
|
Aircraft Operation
|
| Safety Recommendation(s)
|
| Group(s)
|
None Made
|
| Investigation Type
|
| Type
|
Independent
|
Description
On 11 August 2007, a Qantas Boeing 737-400 on a scheduled passenger service from Perth, WA to Sydney, NSW was about three quarters of the way there in day VMC when the master caution light illuminated associated with low output pressure of both main tank fuel pumps. The flight crew then 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 flight was completed without further event.
The Investigation
An Investigation was carried out by the ATSB and found that when the fuel caution was annunciated, each of the two main fuel tanks contained approximately 100 kg of fuel whereas the centre fuel tank contained about 4,700 kg of fuel.
The investigation found that the flight crew had flown the previous two sectors on a B737-800 aircraft which had a different fuel system and fuel control panel. The pilot in command was also considered to have been fatigued during the incident flight as well as suffering from chronic stress and the investigation concluded that it was probable that this stress affected his ability to operate as a pilot in command without him being aware of the condition. In addition, some checklist procedures were not adhered to by the flight crew and it was considered likely that deviations from those checklist items were occurring throughout the operator’s fleet of B737 aircraft. As a result of this investigation, the operator has instigated safety action to change the Before Start and Before Taxi procedures and checklists.
A number of ‘contributing safety factors’ to the occurrence were identified, three of which were flagged as ‘Safety Issues’:
- The Before Start checklist did not distinguish between the various fuel pump selection options. The checklist just called for fuel quantity and Pumps ON.
- The checklist procedure did not require flight crew to touch the switches of the fuel pumps to ensure that they were aware of the position of the switches.
- During the checklist procedure, the copilot would call the check item and then the copilot would check it. There was no crosscheck required by the pilot in command.
Related Articles
Further Reading
