Issue Number 239
May 1999
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Refueling Prospectives

Fuel exhaustion and fuel mismanagement are common causes of engine failures and forced landings. A General Aviation (GA) pilot describes how he and his instructor had to make a forced landing, even after they obtained what they thought was the necessary fuel for their final leg home.

The reporter paid the airfield resident $20, making that a very expensive gallon of fuel. Still, as the reporter concludes, That was one of the best buys I’ve ever made, since it allowed us to fly back to our airport before the engine quit on the ramp—rather than in the air, requiring a real autorotation to the ground.

Another GA pilot also made a precautionary landing when the fuel gauge did not jibe with the planned fuel burn.

Visual inspection of tanks, dipstick measurements, fueling receipts (when available), and fuel gauge readings should all concur. If any one is out of synch with the others, the situation warrants a manual fuel check to verify actual fuel status.

Multiple MissesNext, an air cargo crew missed multiple preflight cues that their fuel state was not as it should be. In portions of the report not cited here, the Captain lists schedule pressure, crew fatigue, and lack of currency as causes of this incident:

As the reporter of another fuel mismanagement incident summed up: Any fuel situation is potentially dangerous, no matter how benign it may appear. As I learned many years ago, fuel in the fuel truck is of little use to a pilot in the air.

Nesting HabitsIn the past, we have shared reports about insect nests found in fuel tank vents and pitot tubes. Here is a report of a new location for those pesky and persistent little wasps known as mud daubers, or dirt daubers. The First Officer of a B-727 cargo flight tells the tale:

HAZMAT  in the Hold

Improper carriage of hazardous materials (hazmat) can pose a serious threat to air safety. A private pilot, traveling as a passenger on a commercial flight, reports on an incident involving a common item that some people might not recognize as a hazardous material.

The reporter notes that the posted hazmat warning at the airline check-in counter referred to "flammable liquids and solids," but matches were not included in the list of examples. He adds that, later, At the ticket counter...they took out from behind the counter a flier stating that matches are prohibited. However, it was not posted where the public could read it, and I would not have thought to ask for the flier if this event had not occurred.

In another incident, a knowledgeable First Officer recognized the danger of carrying two hazardous materials together:

After discussing several notable aircraft accidents attributed to improper handling of hazardous materials, the crew agreed to have the items loaded into separate cargo areas. The First Officer was wise to insist on the safe course of action.

Great Crew Resource Management-- and PilotingSome of the most interesting incidents we hear about at ASRS come to us as brief reports from modest crew members. For example, the following report from an L-1011 Captain did not reveal the gravity of the emergency:

Reports from the First and Second Officers and a callback conversation between the Captain and an ASRS analyst told a much more harrowing story. From the First Officer [FO]:

The Captain was surrounded by inop flags on his instrument panel, so was unsure of which instruments were still operating. Random electrical warnings erroneously indicated that the aircraft was simultaneously on the ground and in the air.

The FO continues:

Cabin pressurization control was switched to standby mode. The SO found a second fire extinguisher and discharged it into the continuing red glow in the circuit breaker panel.

And finally:

The final diagnosis from maintenance personnel: an improperly installed wiring clamp had worn through the insulation and shorted out. Kudos to the flight crew for great crew coordination and superb handling of this aircraft emergency.

ASRS Recently Issued Alerts On...
DC generator shaft failure in an SF34
Missing lug nut on Fokker 100 main wheels
Malfunctioning pilot-controlled lighting at a Georgia airport
Glider activity near the final approach of a Tennessee airport
MD11 cockpit smoke and fumes caused by a burned brake coil
March 1999 Report Intake
 Air Carrier/Air Taxi Pilots
 General Aviation Pilots