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B734, en-route, New South Wales Australia, 2007

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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
Actual or Potential
Event Type
Human Factors, Loss of Control
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 737-400
Operator Qantas
Domicile Australia
Type of Flight Public Transport (Passenger)
Origin Perth International Airport
Intended Destination Sydney Airport
Actual Destination Sydney Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Cruise
ENR
Location En-Route
Origin Perth International Airport
Destination Sydney Airport
Location
Approx. near Mildura City, Australia
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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.

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