Fuel Management Issues - ASRS - Aviation Safety … · · 2017-11-23Fuel Management Issues . ......

ASRS Database Report Set

Fuel Management Issues

Report Set Description .........................................A sampling of reports referencing incidents of fuel mismanagement, and operational concerns for fuel planning.

Update Number ....................................................32.0

Date of Update .....................................................November 30, 2017

Number of Records in Report Set ........................50

Number of New Records in Report Set ...............50

Type of Records in Report Set.............................For each update, new records received at ASRS will displace a like number of the oldest records in the Report Set, with the objective of providing the fifty most recent relevant ASRS Database records. Records within this Report Set have been screened to assure their relevance to the topic.

National Aeronautics and Space Administration

Ames Research Center Moffett Field, CA 94035-1000

TH: 262-7

MEMORANDUM FOR: Recipients of Aviation Safety Reporting System Data

SUBJECT: Data Derived from ASRS Reports

The attached material is furnished pursuant to a request for data from the NASA Aviation Safety Reporting System (ASRS). Recipients of this material are reminded when evaluating these data of the following points.

ASRS reports are submitted voluntarily. The existence in the ASRS database of reports concerning a specific topic cannot, therefore, be used to infer the prevalence of that problem within the National Airspace System.

Information contained in reports submitted to ASRS may be amplified by further contact with the individual who submitted them, but the information provided by the reporter is not investigated further. Such information represents the perspective of the specific individual who is describing their experience and perception of a safety related event.

After preliminary processing, all ASRS reports are de-identified and the identity of the individual who submitted the report is permanently eliminated. All ASRS report processing systems are designed to protect identifying information submitted by reporters; including names, company affiliations, and specific times of incident occurrence. After a report has been de-identified, any verification of information submitted to ASRS would be limited.

The National Aeronautics and Space Administration and its ASRS current contractor, Booz Allen Hamilton, specifically disclaim any responsibility for any interpretation which may be made by others of any material or data furnished by NASA in response to queries of the ASRS database and related materials.

Linda J. Connell, Director NASA Aviation Safety Reporting System

CAVEAT REGARDING USE OF ASRS DATA

Certain caveats apply to the use of ASRS data. All ASRS reports are voluntarily submitted, and thus cannot be considered a measured random sample of the full population of like events. For example, we receive several thousand altitude deviation reports each year. This number may comprise over half of all the altitude deviations that occur, or it may be just a small fraction of total occurrences.

Moreover, not all pilots, controllers, mechanics, flight attendants, dispatchers or other participants in the aviation system are equally aware of the ASRS or may be equally willing to report. Thus, the data can reflect reporting biases. These biases, which are not fully known or measurable, may influence ASRS information. A safety problem such as near midair collisions (NMACs) may appear to be more highly concentrated in area “A” than area “B” simply because the airmen who operate in area “A” are more aware of the ASRS program and more inclined to report should an NMAC occur. Any type of subjective, voluntary reporting will have these limitations related to quantitative statistical analysis.

One thing that can be known from ASRS data is that the number of reports received concerning specific event types represents the lower measure of the true number of such events that are occurring. For example, if ASRS receives 881 reports of track deviations in 2010 (this number is purely hypothetical), then it can be known with some certainty that at least 881 such events have occurred in 2010. With these statistical limitations in mind, we believe that the real power of ASRS data is the qualitative information contained in report narratives. The pilots, controllers, and others who report tell us about aviation safety incidents and situations in detail – explaining what happened, and more importantly, why it happened. Using report narratives effectively requires an extra measure of study, but the knowledge derived is well worth the added effort.

Report Synopses

ACN: 1476733 (1 of 50)

Synopsis A321 Crew reported a problem reprogramming the FMGC after a missed approach.

ACN: 1474184 (2 of 50)

Synopsis Cessna 150 flight instructor reported departing with minimal fuel after founding that fuel

was unavailable at the destination airport when the FBO closed.

ACN: 1474087 (3 of 50)

Synopsis An MD-11 flight crew reported erroneous indications from the fuel systems during climb,

resulting in a return to the departure airport.

ACN: 1473826 (4 of 50)

Synopsis A BE95 Student and Instructor Pilot reported that the left engine failed due to fuel

starvation because he had mistakenly placed the fuel selector switch to "OFF" instead of

"MAIN TANK" during the before landing checklist. The instructor discovered and corrected

the problem and subsequently restarted the engine.

ACN: 1473689 (5 of 50)

Synopsis Flight crew reported windshear warnings while attempting to land at the COS airport that

resulted in two missed approaches. A third attempt was attempted in lieu of a diversion,

and a successful landing was accomplished.

ACN: 1473537 (6 of 50)

Synopsis Aeronca Pilot reported landing in an open field due to a loss of engine power.

ACN: 1473130 (7 of 50)

Synopsis G1159 flight crew reported the #2 engine rolled back in cruise flight at FL400. Engine

relight was successful after descent, and after landing about a cup of water was found

after draining a few gallons from the right fuel tank.

ACN: 1471843 (8 of 50)

Synopsis PA-44 pilot reported the right engine failed on descent into destination airport when the

right fuel tank ran dry.

ACN: 1470687 (9 of 50)

Synopsis Air Carrier Captain reported diverting due to thunderstorms at the destination airport and

fuel concerns.

ACN: 1470577 (10 of 50)

Synopsis B747 flight crew reported beginning to divert due to weather and minimum fuel but ended

up going to the original destination.

ACN: 1470402 (11 of 50)

Synopsis Mooney M20 pilot reported landing on remaining runway after the engine began running

rough shortly after takeoff. Engine ran normally on the ground after switching fuel tanks.

ACN: 1469213 (12 of 50)

Synopsis A PA-18 towing a glider reported a loss of power after takeoff. The pilot quickly recovered

by selecting the other fuel tank and upon landing discovered the initially selected fuel tank

was empty.

ACN: 1468629 (13 of 50)

Synopsis The flight crew of a B747 reported they received an EICAS message "Gear Disagree" and

also had an un-commanded fuel transfer.

ACN: 1468352 (14 of 50)

Synopsis Cessna 560XLS Captain reported that the FAA's ATC system does not seem to recognize

the subsequent altitude changes included in the ICAO flight plan.

ACN: 1468112 (15 of 50)

Synopsis

B787 First Officer reported the controllers at ZSPD did not convey the actual delays to be

expected during arrival, and did not expedite a clearance to the alternate after being

advised of the low fuel state.

ACN: 1467190 (16 of 50)

Synopsis C175 pilot reported a loss of engine power on final approach led to an off-field landing.

ACN: 1467188 (17 of 50)

Synopsis The flight crew of a C-414 reported that the aircraft was fueled using "Jet A" instead of

100 LL fuel.

ACN: 1466184 (18 of 50)

Synopsis A corporate jet First Officer reported a runway excursion when the PIC was unable to stop

the aircraft.

ACN: 1465904 (19 of 50)

Synopsis C177RG pilot reported diverting after the engine began running rough. Problem was later

traced to partially clogged fuel injectors in cylinders #2 and #4.

ACN: 1465525 (20 of 50)

Synopsis Widebody Captain reported encountering un-forecast wind shear and microburst activity

upon arrival at PHX. After 20 minutes of vectoring the crew elected to divert, landing with

10,800 LBS of fuel.

ACN: 1464115 (21 of 50)

Synopsis B737 flight crew reported a windshear encounter while on approach to ORD. They

executed a missed approach and elected to divert due to the weather and their fuel

situation.

ACN: 1463694 (22 of 50)

Synopsis Glider tow pilot reported a loss of power after takeoff that resulted in an early release of

the glider and an off-field landing.

ACN: 1463585 (23 of 50)

Synopsis B737 flight crew reported being dispatched with an MEL for a malfunctioning left wing fuel

quantity indicator. During cruise when the gauge showed zero fuel, the engine began to

lose thrust. The crossfeed was opened, the engine recovered, and the flight diverted.

ACN: 1462890 (24 of 50)

Synopsis An EMB-145's filed destination closed because of weather and a micro-burst alert so the

crew planned a diversion but were advised of a ground stop. As the crew prepared for a

diversion, their destination airport opened and the crew continued on.

ACN: 1462879 (25 of 50)

Synopsis A330 Captain on an intercontinental flight reported a low fuel situation developed when

they had less than forecasted tailwinds. Flight requested a higher altitude with better

winds.

ACN: 1462249 (26 of 50)

Synopsis B737 flight crew and Dispatcher reported a fuel imbalance at cruise and subsequent

diversion.

ACN: 1461603 (27 of 50)

Synopsis Beechcraft Bonanza pilot reported an off-field landing due to loss of power on takeoff

caused by debris in the fuel system.

ACN: 1461572 (28 of 50)

Synopsis Light sport aircraft pilot reported a rough running engine progressed into an engine failure.

The problem was traced to fuel lines that had been incorrectly installed during recent

maintenance.

ACN: 1459617 (29 of 50)

Synopsis A corporate flight crew reported ATC would not issue an IFR clearance because weather

had closed all desired IFR gateways. The crew elected to deviate and continue, their

actions disrupted ATC operations.

ACN: 1459577 (30 of 50)

Synopsis BE76 Safety Pilot reported experiencing an engine failure during an ILS approach.

ACN: 1459305 (31 of 50)

Synopsis EMB-145 First Officer reported the crew failed to shut down Number 2 engine at the gate

while refueling because of distractions and workload.

ACN: 1459271 (32 of 50)

Synopsis B777 First Officer reported returning to departure airport after experiencing fuel system

anomalies.

ACN: 1458556 (33 of 50)

Synopsis B747 flight crew reported being issued a hold without EFC time due to weather.

ACN: 1458298 (34 of 50)

Synopsis Cessna 182 pilot reported landing on a country road due to inadvertently selecting the

"off" position with the fuel selector valve.

ACN: 1458248 (35 of 50)

Synopsis A300 flight crew reported diverting due to unforecast weather combined with inadequate

fuel on board.

ACN: 1457646 (36 of 50)

Synopsis C162 instructor and PA28 pilot reported both aircraft landed on the runway in opposite

directions at the same time. The aircraft both veered to the side to avoid a collision. The

PA28 pilot reported the engine failed and he used the wrong CTAF frequency.

ACN: 1457490 (37 of 50)

Synopsis

ERJ Captain reported receiving a reroute prior to departure from EWR which appeared

shorter than the original route. Once airborne the crew learned of an altitude restriction

that consumed additional fuel, resulting in a diversion.

ACN: 1456951 (38 of 50)

Synopsis PA-25 pilot reported the aircraft lost power at 100 FT AGL when the fuel vent line became

clogged.

ACN: 1456611 (39 of 50)

Synopsis T6 Texan pilot reported an off airport landing due to fuel starvation.

ACN: 1454793 (40 of 50)

Synopsis B737 Captain and Dispatcher reported serious weather that resulted in a diversion to an

offline airport.

ACN: 1454326 (41 of 50)

Synopsis C206 pilot reported he mistakenly positioned the fuel selector to "off" resulting in a loss of

power in flight until he repositioned the selector.

ACN: 1454161 (42 of 50)

Synopsis B767-300 Captain reported a fuel imbalance and FMC message FUEL QTY ERROR-PROG 2

on a trans-oceanic flight. After parking at the gate, ramp personnel reported a significant

fuel leak from the right engine.

ACN: 1453572 (43 of 50)

Synopsis Boeing 777 Captain reported a fuel critical situation during descent due to unforeseen

deviations.

ACN: 1453554 (44 of 50)

Synopsis B777 First Officer reported multiple deviations and delays in flight resulted in the aircraft

landing with emergency fuel.

ACN: 1452522 (45 of 50)

Synopsis B747-400 flight crew reported experiencing a "MAIN CABIN SMOKE" light shortly after

takeoff. Crew elected to return to departure airport.

ACN: 1451548 (46 of 50)

Synopsis BE-35 pilot reported diverting due to a loss of fuel out of the right fuel cap, then diverting

again later after losing power associated with a fuel leak.

ACN: 1451200 (47 of 50)

Synopsis LSA pilot reported an off-airport landing after a fuel miscalculation led to the tanks running

dry.

ACN: 1450668 (48 of 50)

Synopsis C150 pilot reported a loss of engine power on short final due to fuel exhaustion that

resulted in a dead-stick landing.

ACN: 1450636 (49 of 50)

Synopsis C310 pilot reported a complete electrical system failure in visual conditions that resulted in

a diversion to a nearby airport.

ACN: 1450417 (50 of 50)

Synopsis B737 Dispatcher reported a flight had a MCP failure after takeoff and advised the Captain

to return to the departure airport.

Report Narratives

ACN: 1476733 (1 of 50)

Time / Day

Date : 201708

Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US

Environment

Flight Conditions : IMC

Weather Elements / Visibility : Thunderstorm

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ

Aircraft Operator : Air Carrier

Make Model Name : A321

Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 121

Flight Plan : IFR

Mission : Passenger

Flight Phase : Initial Approach

Airspace.Class B : ZZZ

Component

Aircraft Component : FMS/FMC

Aircraft Reference : X

Problem : Malfunctioning

Person : 1

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck

Reporter Organization : Air Carrier

Function.Flight Crew : First Officer

Function.Flight Crew : Pilot Flying

Qualification.Flight Crew : Air Transport Pilot (ATP)

ASRS Report Number.Accession Number : 1476733

Person : 2

Reference : 2




Function.Flight Crew : Captain

Function.Flight Crew : Pilot Not Flying


Experience.Flight Crew.Total : 27000


Events

Anomaly.Aircraft Equipment Problem : Critical

Anomaly.Inflight Event / Encounter : Fuel Issue

Detector.Person : Flight Crew

When Detected : In-flight

Result.Flight Crew : Executed Go Around / Missed Approach

Result.Flight Crew : Overcame Equipment Problem

Assessments

Contributing Factors / Situations : Aircraft

Contributing Factors / Situations : Weather

Primary Problem : Aircraft

Narrative: 1

After an extensive hold while approaching minimum fuel we were cleared for an ILS. The

captain and I agreed that we had adequate fuel for two attempts at landing before

necessitating a diversion to our flight planned alternate. The weather dropped below

minima necessitating a go around. A go around was executed and performed per company

policy and standard operating procedures. Once ATC vectored us off of the missed

approach the captain began to reconfigure the FMS for our second attempt. We received a

series of faults in rapid succession that ultimately resulted in a non-recovering dual FMGC

failure.

We notified ATC of our primary navigation failures. As we held we began approaching

minimum fuel, while negotiating weather, and attempting to problem shoot the multiple

failures. After a brief time we were able to reload the FMGC and input our destination and

the appropriate approach. However, the FMGC would not accept the Cruise altitude input

to force the FMGC into cruise mode. It was returning an error message. In effect it was

stuck in takeoff mode, and would not sequence to later in the flight. After a brief

discussion we decided to attempt to quickly advance the thrust into TOGA and then return

to the climb detent and rebuild the automation.

I pushed the thrust levers to toga, and immediately returned them to the climb detent.

The aircraft began climbing as expected, I selected altitude hold, and pulled selected

speed. The autopilot did not acknowledge my inputs. I attempted each multiple times. In

order to prevent an altitude deviation, or a flap overspeed I disconnected the autopilot and

engaged manual thrust.

At this point everything was stabilized. We had not deviated from our altitudes, heading or

assigned airspeeds. We reselected the vertical mode, and received an altitude capture. We

reengaged the autopilot. I returned the thrust levers to the climb detent expecting the

auto thrust to recapture. I noticed that this did not happen, and retarded the throttles.

Moments later a minor flap exceedance was experienced. Fortunately, this maneuver

properly sequenced the FMGC and we were able to continue our approach to landing. Upon

landing we entered the FMGC failures as well as the flap exceedance into the [maintenance

log]. Multiple complex system failures, during critical phase of flight, with adverse

weather, and near minimal fuel considerations.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

A321 Crew reported a problem reprogramming the FMGC after a missed approach.

ACN: 1474184 (2 of 50)

Time / Day

Date : 201708


Place



Altitude.AGL.Single Value : 0

Environment

Flight Conditions : VMC

Light : Night

Aircraft

Reference : X

Aircraft Operator : FBO

Make Model Name : Cessna 150



Flight Plan : None

Mission : Training

Route In Use : Direct

Person

Reference : 1



Reporter Organization : FBO

Function.Flight Crew : Instructor

Qualification.Flight Crew : Instrument

Qualification.Flight Crew : Commercial

Qualification.Flight Crew : Flight Instructor


Experience.Flight Crew.Last 90 Days : 150

Experience.Flight Crew.Type : 250


Human Factors : Time Pressure

Human Factors : Situational Awareness

Events

Anomaly.Deviation - Procedural : Published Material / Policy

Anomaly.Deviation - Procedural : FAR

Anomaly.Ground Event / Encounter : Other / Unknown



When Detected : Taxi

Result.Flight Crew : Landed As Precaution

Result.Flight Crew : Diverted

Assessments


Contributing Factors / Situations : Human Factors

Primary Problem : Human Factors

Narrative: 1

A student and I departed on a night cross country flight to ZZZ. We were at maximum

gross weight with 16 gallons of fuel in our tanks. 3.5 gallons of fuel is unusable, meaning

we had 12.5 usable gallons onboard. The 1-hour flight to ZZZ would take 1 hour, meaning

we would have burned 6 gallons. Usable fuel remaining would be 6.5 gallons. A flight back

to our home airport would take roughly 30 minutes, meaning we would only have 3.5

usable gallons remaining after we landed back home if we did not refuel. Therefore we

knew we would need to re-fuel before heading home.

My personal minimum is to have 1 hour of fuel remaining after each flight. The TAFs in our

area were forecasting MVFR and IFR weather to arrive within 6 hours. This region is known

for having bad weather arrive earlier than forecast. Therefore I wanted more than 1 hour

of fuel to be in the tanks after we landed at our home airport so that we wouldn't be left

without ample options to find a different place to land if the weather rolled in early.

[By the time] we landed at ZZZ, both FBOs had closed. No self-serve fuel was available.

Neither of us realized this until after we landed at ZZZ. Further complicating the matter is

the fact that no airports on the way home had self-serve fuel. Rather than pay a fee for a

line service after-hours call, we elected to go to a nearby airport to refuel. We chose ZZZ1,

which had low-intensity runway lighting and self-serve fuel available, or so we thought. So

we departed towards ZZZ1. The total enroute time was 20 minutes. We estimated we

would have 4 usable gallons remaining. This was legal per actual fuel consumption

numbers, but per a conservative burn rate estimate, it would have been below my

personal minimums. I had not realized this until later when I would write this report.

When we arrived over ZZZ1, we realized that the low-intensity runway lights were

inoperative. This was an unexpected problem. Further complicating the matter is that this

airport is located in essentially the middle of nowhere. I could see the beacon briefly

illuminate portions of the pavement as it rotated around, but I could not take the chance

at landing on a dark runway in unfamiliar territory. With 4 usable gallons remaining, we

were now technically in emergency fuel status, but did not realize it at the time. We did

know, however, that our fuel situation was getting uncomfortably tight.

We had to make the decision to go back to ZZZ or choose another airport. We believed

ZZZ would be slightly upwind and another airport to be slightly downwind based on our

wind aloft estimations. The slightly downwind airport was ZZZ2, and it had self-serve fuel.

The total time to ZZZ2 would be about 25 minutes. A conservative fuel burn estimate of 6

gallons/hour would mean we would use 3 gallons. In writing this report, I realize that

would leave us with 1 usable gallon remaining. While actually flying the leg, I failed to

account for the "unusable" fuel and figured we would land with 5 gallons, failing to

remember that 3.5 gallons of that would be unusable. I believe I was in denial about the

whole situation.

I notified the overlying approach control of the lighting situation at ZZZ1 and requested

flight following to ZZZ2. The Approach Controller acknowledged my report and provided us

with radar flight following to ZZZ2.

Thankfully, all of our fuel calculation with a 20% more conservative burn rate than what is

published in the POH. Despite knowing we had inflated the burn rate to be conservative, I

was extremely nervous going into ZZZ2 because of the thought of exhausting all of our

usable fuel. We made it to ZZZ2 without incident. When I exited the airplane, I used a

dipstick to measure the fuel tank quantity. We had 2.5 gallons per tank for a total of 5

gallons remaining. 3.5 of those total gallons are unusable, meaning we had 1.5 gallons of

usable fuel remaining. This was both illegal and below my personal minimums. I was

horrified at what had happened.

The chain of events went as follows: We depart at maximum gross weight with 16 gallons

of fuel. We plan to arrive at an airport before the FBOs close, but land later than planned.

Not wanting to pay an FBO call out fee, we depart for a nearby airport that has both

runway lighting and self-serve fuel advertised in the Chart Supplement U.S. We arrive at

the nearby airport with minimum fuel only to find the runway lighting inoperative. We

make a decision to go to another airport that is downwind of the wind aloft and end up

landing with 1 gallon of usable fuel, or 10 minutes of usable fuel remaining.

This whole incident has resulted in a big change in approach to how I will conduct night

cross country training in the future. First, our SOPs will be amended as follows:

1. Flights to any airport must have an ETA of no later than 1 hour prior to the closing time

of airport fuel vendors if the destination does not have self-serve fuel available.

2. Night flights must have enough usable fuel onboard to reach two alternate airports,

both of which must have fuel available and airfield lighting.

3. In the event a flight lands at the planned destination and no fuel vendors or self-serve

fuel are available, students are required to pay the call out fee to refuel. At night, the

alternate airports may be flown to only if a call out is not possible.

Next, I will be more involved in the cross country planning of my students. I should have

recognized the fact that ZZZ had no fueling available well prior to arriving there after the

FBOs had closed. And I should have required my student to pay a call out fee rather than

agreeing to fly somewhere else considering that we didn't have legal fuel remaining to

make it to an alternate should our refueling airport be closed, or in this case, should our

refueling airport have an unexpected lighting outage.

I reported the outage to the overlying approach control listed in this report. I then called

FSS in the morning to report the outage. The Approach Controller seemed uninterested in

the problem, and the FSS specialist referred me to the airport administration. When I

called the airport administration, the manager was unavailable, and I was told to leave a

message. To this day, 48 hours later, the problem has not been fixed, and no NOTAM has

been issued.

Synopsis

Cessna 150 flight instructor reported departing with minimal fuel after founding that fuel

was unavailable at the destination airport when the FBO closed.

ACN: 1474087 (3 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZZZZ.ARTCC

State Reference : FO

Altitude.MSL.Single Value : 35000

Environment


Aircraft

Reference : X

ATC / Advisory.Center : ZZZZ


Make Model Name : MD-11



Flight Plan : IFR

Mission : Cargo / Freight

Flight Phase : Cruise

Airspace.Class A : ZZZZ

Component

Aircraft Component : Fuel Quantity-Pressure Indication



Person : 1

Reference : 1








Person : 2

Reference : 2

Location Of Person : Company


Function.Dispatch : Dispatcher

Qualification.Dispatch : Dispatcher


Person : 3

Reference : 3








Events




Detector.Automation : Aircraft Other Automation



Result.Flight Crew : Returned To Departure Airport

Result.Flight Crew : Requested ATC Assistance / Clarification


Result.Air Traffic Control : Provided Assistance

Assessments



Narrative: 1

During climb out we received a level 1 alert indicating the Manifold Drain valve was open.

Utilizing the QRH we verified the switch was actually not in the open position, verified the

light bulb was operable, and the QRH consequence of not utilizing the cross-feed manifold

as the fuel would drain if it were open. This was followed by another alert Tank 2 LOW

with an indication of ZERO fuel on the synoptic display. Engine 2 continued to operate. The

tank lo alert disappeared, we cycled to manual and back to automatic on the Fuel

Controller and the Manifold Drain alert disappeared.

Almost immediately later at the top of climb the above two alerts re-appeared with zero

again in tank 2 but with 600 LBS and 1200 LBS of fuel in tank 1 & 3 respectively without

tank 1 & 3 low alerts. The Fuel Quantity/Used Check along with a WHITE "possible fuel

leak" alert displayed on the Fuel synoptic. Captain requested and executed an immediate

turn-back and when queried if it was a mayday event replied yes. We received excellent

ATC support and flew directly back to the airport. The procedures for preparing to return

went exceptionally smooth after the event. We approached high and fast just in case and

had time to re-verify our fuel, discuss airspeeds and take pictures of the status on the

synoptic displays. At the FAF, we were stable and in the groove followed by an uneventful

landing. The fuel system went back to normal and the 32,000 LBS of actual fuel on board

was on display.

The fuel system was giving erroneous indications first with a manifold drain valve alert

suggesting the drain valve was open and to not utilize cross-feed. We verified the alert

was questionable by observing that the Manifold Drain switch did not indicate open and

the bulb was verified operable. The second alert indicated Tank number 2 fuel was low and

the indication was ZERO 0! Engine two continued to operate without cross-feed so again

we verified the alert was probably erroneous. The follow on alerts were an escalation of

more suspected indications but were treated as possibly actual as there is no way of

knowing with certainty that they were erroneous.

Narrative: 2

Received diversion report from [this] flight as it approached top of climb. ACARs sent to

crew, they confirmed returning to [the airport] due to fuel quantity issue. Aircraft landed

safely, after which Captain called on to advise they had received multiple fuel quantity,

fuel low and fuel manifold alerts and were unable to determine exactly how much fuel was

on aircraft. Crew did [informed of the mayday event] on the return, no fuel was dumped.

[Supervisor] notified manager on duty (no airport manager present) and I notified duty

officer and submitted shift note as per procedure. At time of [this report], aircraft is still

down in at the airport and next leg will likely cancel.

Narrative: 3

Just after top of climb at FL 350, we received the following alerts: Fuel Manifold Drain,

Fuel Quantity/Used Check, and TANK 2 Fuel Quantity Low. Fuel tank quantities indicated

600, 0, 1200 respectively. Totalizer showed 1800 LBS remaining. We had departed with

46,800 LBS. We [informed ATC], ran the QRH procedures and were expedited back to the

airport. Landing and taxi back to parking were uneventful.

My First Officer did an outstanding job coordinating and planning the turn back to the

airfield. He also reminded me to check my AOA (Angle Of Attack) on final. We did bump up

the speed a few knots to bring us into the lower part of the AOA band. After landing the

fuel systems returned to normal indications.

Synopsis

An MD-11 flight crew reported erroneous indications from the fuel systems during climb,

resulting in a return to the departure airport.

ACN: 1473826 (4 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : BNA.Airport

State Reference : TN

Relative Position.Distance.Nautical Miles : 7


Environment

Flight Conditions : Mixed

Weather Elements / Visibility : Haze / Smoke

Weather Elements / Visibility.Visibility : 6

Ceiling.Single Value : 2500

Aircraft

Reference : X

ATC / Advisory.Tower : BNA


Make Model Name : Travelair 95



Flight Plan : IFR

Mission : Training

Nav In Use.Localizer/Glideslope/ILS : Runway 20C

Flight Phase : Final Approach

Airspace.Class C : BNA

Component : 1

Aircraft Component : Engine


Problem : Failed

Component : 2

Aircraft Component : Fuel Selector


Problem : Improperly Operated

Component : 3

Aircraft Component : VHF


Person : 1

Reference : 1





Function.Flight Crew : Trainee








Human Factors : Training / Qualification

Human Factors : Confusion

Person : 2

Reference : 2







Qualification.Flight Crew : Multiengine



Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.ATC Issue : All Types







Result.Flight Crew : Became Reoriented


Result.Aircraft : Equipment Problem Dissipated

Assessments

Contributing Factors / Situations : Environment - Non Weather Related



Narrative: 1

The incident happened while tracking the ILS inbound to 20 center at BNA. This being my

first flight in this aircraft, as well as my first flight in a multi engine aircraft, I was still

adjusting to the aircraft while I also attempted to run through the pre-landing check list.

One of the items on this list is to switch the fuel lines from auxiliary to mains, and in doing

so I unknowingly switched the fuel line to the left engine into the off position instead of

the main position. The engine began to fail, and at this time, unbeknownst to us, the

comm button on the copilot side got stuck. We declared the engine out but failed to

receive any transmissions back from tower for several minutes. After troubleshooting the

issue, we uncovered my mistake and successfully restarted the engine and continued the

approach. It wasn't until we were clear of the active runway that we were able to resolve

the comms issue.

Narrative: 2

I was conducting flight training with a student and I was occupying the co-pilots seat.

Using the "before landing checklist" I asked the student to switch the fuel selector from

the AUX position to the main position for landing. The student inadvertently switched the

fuel selector to the OFF position on the left engine without my knowledge. Consequently

the left engine started to fail. I took control of the aircraft. Feathered the propeller, and

transmitted to Approach Control that I had an emergency, and engine failure and was

landing visually on runway 20L. I had no response from Approach Control at this time. I

then proceeded to troubleshoot the cause and discovered that the left engine fuel selector

switch had been placed in the "OFF" position by the student. I immediately placed the

switch to the "main tank" position and re-started the engine.

I then transmitted to Approach Control that the emergency situation had been resolved

and that I was landing visually on Runway 20L. No response was received from Approach

Control. I then attempted to contact the tower but no response. I then went back to

Approach Control and asked the controller if I had been cleared to land, she informed me

of a stuck mike and to contact tower. I again attempted to contact the tower but to no

avail. I received a green light from the tower to land. I landed and cleared the runway and

in a few moments was able to use the radio and communicated with Ground Control. In

retrospect, I should have confirmed that the fuel selector switch had been placed in the

proper position. The student prior to flight had thoroughly been taught the fuel system.

Synopsis

A BE95 Student and Instructor Pilot reported that the left engine failed due to fuel

starvation because he had mistakenly placed the fuel selector switch to "OFF" instead of

"MAIN TANK" during the before landing checklist. The instructor discovered and corrected

the problem and subsequently restarted the engine.

ACN: 1473689 (5 of 50)

Time / Day

Date : 201708


Place

Locale Reference.Airport : COS.Airport

State Reference : CO


Environment



Weather Elements / Visibility : Turbulence

Weather Elements / Visibility : Windshear

Light : Daylight

Aircraft

Reference : X


Make Model Name : Medium Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Flight Phase : Landing

Person : 1

Reference : 1









Person : 2

Reference : 2








Events

Anomaly.Deviation - Speed : All Types

Anomaly.Inflight Event / Encounter : Unstabilized Approach

Anomaly.Inflight Event / Encounter : Weather / Turbulence





Assessments


Primary Problem : Weather

Narrative: 1

The flight started normally. My First Officer (FO) and I discussed the weather surrounding

COS before and during the flight. Noticeable virga was on the approach end about 10

miles north of 17L. The airport was not reporting windshear or wind gusts on the last

ATIS. A flaps 45 landing was used on the first approach. A red wind shear appeared and

we executed a go-around. I am not sure, but we may have gone over 200 kts during the

go-around in Class C. The weather was still VFR for COS and the storms were moving

away from the airport. The weather had thunderstorm activity between COS and our filed

alternate. A quick discussion of our options resulted in another attempt to land at COS. On

the second approach, we used a flaps 22 landing. Another red windshear appeared and we

once again executed another go-around. Our best option still appeared to be another

attempt to land at COS, but on the third attempt I flew the approach. For the third time,

we got another windshear warning that quickly went away along with a soft "sink rate,

sink rate".

With the fuel running low, a flight to KDEN would have put us in a min fuel status and

there was weather that would require additional vectors off course. On all three

approaches, the windshear felt minimal and I did not expect to get a windshear message

with the storms at its distance away from the field. Although we were told the storms were

moving away from the field, I did not want to risk having the storm change directions and

further limit our options. Also, the windshear message went away and I adjusted the

aircraft to not allow another sink rate aural message. After quickly reviewing our options,

we agreed to continue the approach and land in the interest of safety. The aircraft was

fully configured above 1000 AGL and no aircraft limitations were exceeded, although I was

fast on the approach.

The threats included windshear, thunderstorms in the vicinity, thunderstorms enroute to

our filed alternate, thunderstorms approaching our filed alternate, a high workload

environment, and a steadily decreasing amount of fuel.

Narrative: 2

After a normal flight with myself as pilot flying, during our arrival brief the Captain and I

briefed the possibility of a go around due to a small thunderstorm north of the COS airport

and the steps involved in go around. Our alternate was DEN with thunderstorms expected

in the vicinity. As we approached the field, still with approach control, we visually saw the

thunderstorm which was about 6 miles north of the 17L runway. Approach informed us

about the thunderstorm as well and said no aircraft had any issues with getting in and no

unusual weather alerts were given. It was my leg to fly, the Captain and I briefed the risks

and that we would need to be fully configured early to avoid an unstable approach. This

would be a flaps 45 landing. Flaps 8 was called for early and then gear down and flaps 22

was called for on our extended left base and inside outer marker. Turning final, I asked for

flaps 45 and landing check. I was a little high and corrected and was stabilized by 1000

feet, I believe about 1 to 1.5 miles from the end of runway we received a Windshear red

alert, thus we executed a go-around. We climbed out to our assigned altitude and

reconfigured, briefed what happened and I quickly asked either the tower or the approach

control, what direction the thunderstorm was moving, they said storm was basically

moving ENE away from the field. The Captain and I briefed the approach and landing

again, believing that it was safe to execute another approach and landing, but instead

using flaps 22. We executed the approach with the same result, a Windshear almost in the

same spot. We executed a go around and after a quick discussion and review of the

weather and weather at the alternate, I transferred the controls to the Captain so he could

execute the approach in the interest of safety. We briefed the weather/risks, approach and

landing, and executed a flaps 22 landing with the same results, a Windshear warning,

however, the warning was only on for a matter of maybe 2 seconds and went away then a

soft sink rate, however quickly went away. After a quick discussion we both felt the safest

option was to land the aircraft. The short final was stable, however fast (which was

briefed) and we landed with no further issue. At no time did I feel nervous or that we were

operating in a unsafe manner. I believe the Captain acted and operated in the most

professional manner. Threats included windshear, thunderstorms in the vicinity,

thunderstorms enroute to and at our alternate, a high workload environment and a always

decreasing amount of fuel. After first approach and go around we could have diverted to

our alternate, however before we even left ZZZ I checked the radar and Denver had

thunderstorms building to the west and south west and also Pueblo would normally be a

good alternate but they had storms as well. We could have diverted to the alternate with

the same results, but with landing with even lower fuel. We could have executed a hold

but, according to controllers, the storm was not moving much.

Synopsis

Flight crew reported windshear warnings while attempting to land at the COS airport that

resulted in two missed approaches. A third attempt was attempted in lieu of a diversion,

and a successful landing was accomplished.

ACN: 1473537 (6 of 50)

Time / Day

Date : 201708


Place




Environment



Weather Elements / Visibility : Rain


Light : Daylight


Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ

Aircraft Operator : Personal

Make Model Name : Aeronca Champion



Flight Plan : VFR

Mission : Training


Route In Use : Visual Approach

Airspace.Class E : ZZZ

Component

Aircraft Component : Powerplant Fuel System



Person

Reference : 1



Reporter Organization : Personal







Human Factors : Troubleshooting


Analyst Callback : Completed

Events






Result.Flight Crew : Landed in Emergency Condition


Assessments



Narrative: 1

On the way to ZZZ airport to get fuel the engine started to stutter. I immediately pulled

carb heat, verified mixture full rich, and fuel selector on, fuel gauge showing to have fuel,

oil pressure and temperature both in the green. I continually pumped the throttle, as that

seemed to be the only thing to keep the engine running partially. I looked for the private

grass strips that I know of in the area, I was too far and too low to make it to them so I

continued toward the best field options I could see when I remembered a friend of my

boss had a big field he said we could land at just north of ZZZ. I then located the field and

proceeded to circle the field while performing my final check list. I secured the engine and

preformed a textbook 3 point soft field landing. I called my boss and he promptly arrived

with an aircraft mechanic to inspect the airplane. They found absolutely no evidence of a

problem so they started the airplane and my boss flew it back to the airport where he

could have it checked tested and fixed. No one was injured, no damage to persons or

property occurred, and the airplane was in perfect flying condition. The airplane is now

grounded until the issue can be found, however, my boss could not duplicate the issue and

the engine ran perfectly smooth on the way back to the airport. The only thing they could

come up with to this point is carb ice or vapor lock. Those are just guesses seeing how the

issue cannot be duplicated. Also, I used carb heat and it only seemed to escalate the

issue, progressively losing power and never restoring fuel flow. When pumping the throttle

the engine would start back up for about a second per pump. This continued for about 2

minutes before it stopped healing and the engine stopped completely.

Callback: 1

The reporter stated that the field where he made the emergency landing was a field that

they used for practicing soft field landing. He added that maintenance has replaced the

fuel line precautionary and ensured that the carb heat was working properly. They were

unable to determine the actual cause of the engine shutting down, but suspect icing was

the probable cause since the aircraft has been operating normally since the incident.

Synopsis

Aeronca Pilot reported landing in an open field due to a loss of engine power.

ACN: 1473130 (7 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment




Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZZZ

Aircraft Operator : Corporate

Make Model Name : Gulfstream II (G1159)



Flight Plan : IFR

Mission : Personal



Airspace.Class A : ZZZ

Component : 1

Aircraft Component : Turbine Engine


Problem : Failed

Component : 2

Aircraft Component : Fuel


Person : 1

Reference : 1



Reporter Organization : Corporate











Person : 2

Reference : 2














Events





Result.General : Maintenance Action


Result.Flight Crew : Inflight Shutdown




Result.Air Traffic Control : Issued New Clearance

Assessments



Narrative: 1

We were cruising at FL400 when right engine rolled back. Turned ON ignition, engine

would not re-light, [advised ATC]. Requested descent to FL300. Donned oxygen mask.

Engine restarted about FL310, leveled at FL300. Requested a nearby airport for landing.

Next day, drained several times some fuel from each wing tank sumps about 1-2 gallons

each to find about a cup of water in the right fuel tank. No water was further found.

Restarted both engine to find all is normal. Mechanic's belief is [the] water interrupted the

fuel to the engine to cause a rollback.

Narrative: 2


Synopsis

G1159 flight crew reported the #2 engine rolled back in cruise flight at FL400. Engine

relight was successful after descent, and after landing about a cup of water was found

after draining a few gallons from the right fuel tank.

ACN: 1471843 (8 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : PA-44 Seminole/Turbo Seminole



Flight Plan : IFR

Mission : Training

Flight Phase : Descent

Route In Use : Vectors


Component



Problem : Failed

Person

Reference : 1





Function.Flight Crew : Single Pilot


Qualification.Flight Crew : Private







Events










Assessments




Narrative: 1

During preflight I visually inspected the fuel, and could see that there was fuel, but did not

physically verify. Also checked the fuel level gauges which both indicated full tanks.

Concluded that there was enough fuel in order to complete the flight. Upon descent we

experienced a right engine failure and determined that it was caused by insufficient fuel in

the right tank. The fuel gauge had rapidly dropped to zero, and we had a complete loss of

fuel pressure. After running an emergency checklist I contacted ATC. ATC gave [us]

vectors [and] we made a visual landing without incident. This situation could have been

avoided by physically verifying fuel level in both tanks instead of relying on the fuel level

indications on the gauges.

Synopsis

PA-44 pilot reported the right engine failed on descent into destination airport when the

right fuel tank ran dry.

ACN: 1470687 (9 of 50)

Time / Day

Date : 201708


Place

Locale Reference.ATC Facility : ZOB.ARTCC

State Reference : OH

Environment



Light : Night

Aircraft

Reference : X

ATC / Advisory.Center : ZOB


Make Model Name : Commercial Fixed Wing



Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZOB

Person

Reference : 1









Events




Were Passengers Involved In Event : N



Result.Air Traffic Control : Issued Advisory / Alert

Assessments



Narrative: 1

Original flight scheduled to ROC, diverted to ZZZ due to TRs at ROC. At the folder noticed

fuel was about 10.3 at ROC no alternate with lots of weather in route. I added 3k. After

takeoff ATC leveled us at 310 initially. They said this would be a final. Sent [Operations] a

msg. After a bit they gave us 330 as a final. Enroute we have to deviate for WX quite a bit.

On arrival several thunderstorms in the area. We flew over ZZZ and it looked fine. Noticed

the radar displayed strong storms east and southeast and south of ROC and closing in on

the airport. We were getting vectors for the approach and handed off to tower. We were

on a right dogleg and Tower reported winds gusting to 30 and the last jet that attempted

to land was an Airbus 319 that reported +\- 15 and a 600 ft loss on final. I could see the

strong rain down shafts and lightning almost at the field and discontinued the approach. At

this point we had about 11k on gas. I knew ZZZ was clear and I decided to go. ZZZ is a

very short flight from ROC. The FO (First Officer) was flying and I was getting our

clearance to ZZZ as well as diverting the box, loading the app, getting ATIS, working the

radar, and doing landing data. We landed and I called [Operations] then because I just flat

didn't have time to tell them in flight, very time compressed. We blocked in with 8.9 fob

(Fuel on Board). 1900 lbs above emergency fuel, glad I added 3k.

Synopsis

Air Carrier Captain reported diverting due to thunderstorms at the destination airport and

fuel concerns.

ACN: 1470577 (10 of 50)

Time / Day

Date : 201708


Place




Environment





Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ



Make Model Name : B747 Undifferentiated or Other Model



Flight Plan : IFR

Nav In Use : FMS Or FMC




Person : 1

Reference : 1











Human Factors : Communication Breakdown

Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : ATC

Person : 2

Reference : 2




Function.Flight Crew : Relief Pilot






Person : 3

Reference : 3










Events


Anomaly.Deviation - Procedural : Clearance


Anomaly.Inflight Event / Encounter : Unstabilized Approach





Assessments




Narrative: 1

We were on the approach to ZZZ, about 18 mile final and were watching a large storm cell

over the airport. As we got closer ATC issued a micro burst alert for 50 knot wind gains

and losses on final. We elected to abandon the approach and since the cell appeared to be

moving quickly across the field, we elected to have delay vectors to evaluate the rapidly

changing weather. We had about 1+20 minutes of fuel remaining. We were sent on a

heading to ZZZZZ and switched to ZZZ1 approach. The controller there had clearly lost

the picture of his traffic situation and did not answer our initial transmissions. We

continued to have difficulty establishing communication with approach. The IRO

(International Relief Officer) was communicating with dispatch to change our alternate to

something closer to our current position than ZZZ2, but were told that none of the local

area airports were suitable. We evaluated our fuel state and determined that we needed to

divert to ZZZ2 without delay to arrive with sufficient fuel. Again, the controller seemed to

not hear our transmissions and at one point made a blind broadcast to us by our

transponder code. We finally got a heading to ZZZ2 after declaring minimum fuel. In

addition, we had to deviate around scattered cells as we headed to ZZZ2. We were

switched to ZZZ approach as we had to go by ZZZ on our way to ZZZ. The controller

informed us that Runway XYR was available for landing if we wanted it. We evaluated the

situation and saw a large gap between cells that would allow a visual approach. We were

vectored till we saw the airport and were cleared for a visual approach to XYR. I noticed

the First Officer appeared to have the wrong runway in sight and was slightly high on the

approach. He reported XYR in sight and I was providing verbal corrections to position us

for the visual approach. We had to maneuver around a rain shower between us and the

runway and I noticed we were trending to low when we got a below glide slope alert. We

immediately corrected back to course and because of our position on an angling left base,

we needed to make a turn to line up with the runway at 700 feet. My normal reaction is

not to try to salvage a bad approach, but to go around and do it again. I felt that

considering our fuel state, about 40 min remaining, and the rapidly changing weather we

needed to land rather than go around, and that we could do it safely. The approach

resembled the IGS [Instrument Guidance System] into the old Hong Kong airport. We

were lined up and on speed at 400 feet and the wind at the airport remained less than 5

knots. We landed exactly in the touchdown zone and taxied to the gate without further

incident.

Narrative: 2


Narrative: 3


Synopsis

B747 flight crew reported beginning to divert due to weather and minimum fuel but ended

up going to the original destination.

ACN: 1470402 (11 of 50)

Time / Day

Date : 201708


Place



Environment



Light : Daylight

Ceiling : CLR

Aircraft

Reference : X



Make Model Name : Mooney Aircraft Undifferentiated or Other Model


Flight Plan : None

Mission : Personal

Flight Phase : Initial Climb

Route In Use : None

Airspace.Class D : ZZZ

Component : 1




Component : 2

Aircraft Component : Fuel System



Person

Reference : 1










Events







Assessments




Narrative: 1

Contacted ground for taxi to takeoff. After run up cleared for takeoff. Just after liftoff the

engine started to run very rough. Pushed over to maintain gliding speed and flared with a

successful touch down on the remaining runway. After clearing the active runway the

engine shut down. Switched tanks and was able to restart the engine and taxied to the

ramp.

Synopsis

Mooney M20 pilot reported landing on remaining runway after the engine began running

rough shortly after takeoff. Engine ran normally on the ground after switching fuel tanks.

ACN: 1469213 (12 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight

Aircraft : 1

Reference : X


Make Model Name : PA-18/19 Super Cub



Flight Plan : VFR


Route In Use : None

Airspace.Class G : ZZZ

Aircraft : 2

Reference : Y

Make Model Name : Sail Plane




Component



Problem : Design

Person

Reference : 1











Human Factors : Human-Machine Interface


Human Factors : Workload

Events






Result.Flight Crew : Took Evasive Action


Assessments



Contributing Factors / Situations : Procedure


Narrative: 1

While conducting glider towing operations, I was the only pilot in the tow plane with a

glider in tow. During initial climb out at full power (at approximately 500 ft AGL), my

airplane experienced a sudden power loss. I immediately switched fuel tanks and power

was restored. However, during the period of power loss the tow plane descended relative

to the glider, who therefore wisely disconnected the towline from his end and conducted a

flawless return to the takeoff point. Meanwhile, with power restored but not certain why I

had lost power, I climbed approximately 1,500 feet AGL over the runway (a private grass

strip), from which point I conducted an idle descent and landing. After landing, I

conducted a power check (magnetos) which normal results. After shutting down, I

examined the aircraft's fuel quantity and discovered that the initially-selected tank (LEFT)

appeared empty. The right tank contained an estimated 1.5 hours of fuel (approximately

10 gal). I had, until this point, estimated my left tank as containing at least 5 gallons of

fuel and planned to switch to the right tank after the tow that was being conducted. The

aircraft's fuel quantity indications are sight glasses on the inboard wing root, in the

cockpit's overhead and are known to be poor, especially on uneven ground. We added fuel

into the left tank, debriefed the event and continued operations without further incident.

Synopsis

A PA-18 towing a glider reported a loss of power after takeoff. The pilot quickly recovered

by selecting the other fuel tank and upon landing discovered the initially selected fuel tank

was empty.

ACN: 1468629 (13 of 50)

Time / Day

Date : 201707


Place




Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR


Flight Phase : Climb

Component : 1

Aircraft Component : Landing Gear Indicating System



Component : 2

Aircraft Component : Fuel Distribution System

Problem : Failed

Person : 1

Reference : 1












Person : 2

Reference : 2











Person : 3

Reference : 3




Function.Flight Crew : Other / Unknown





Events


Anomaly.Deviation - Procedural : Weight And Balance



Detector.Automation : Aircraft Other Automation






Assessments



Narrative: 1

After rotation with the positive rate gear up call the gear handle was raised and we

received the ECIAS message Gear Disagree. We continued with the departure and I

advised the IRO (International Relief Officer) to read the QRH procedure. We advised ATC

we had a Gear problem and advised them of our situation. I contacted Flight Control and

with Maintenance, Dispatch, and a SME (Subject Matter Expert) we discussed the problem

and determined that the best course of action was return to [the airport]. Dispatch sent an

ARTR (Amended Release to Read) and we dumped fuel for the return. On the STAR we

received an EICAS Fuel Imbalance 1 and 4 followed by EICAS Fuel Imbalance 2 and 3. All

attempts using the QRH Procedures proved unsuccessful. Fuel imbalance continued to

deteriorate. Fuel was draining out of Tank 1 rapidly. We then ran the fuel leak checklist.

We determined that the fuel was not leaking externally but going into tank Number 2. The

fuel would not stop draining from tank Number 1 into tank Number 2. We looked for

further guidance in the QRH but could not find any. Using system knowledge we chose to

open the cross feed and feed engine Number 1 from tank 2 and turn off the pumps on

engine Number 1. The fuel continued to leave tank 1 and go into tank 2. Upon landing the

difference between tank 1 and 4 was 10,000 pounds. The fuel imbalance 2-3 was brought

back into tolerance by using tank 2 to feed 1,2, and 3 engines. When tank 1 continued to

drain uncommanded we declared PAN PAN PAN at which time ATC gave us expedited

handling. Landing was uneventful.

Narrative: 2


Narrative: 3


Synopsis

The flight crew of a B747 reported they received an EICAS message "Gear Disagree" and

also had an un-commanded fuel transfer.

ACN: 1468352 (14 of 50)

Time / Day

Date : 201707

Place


Aircraft

Reference : X

Aircraft Operator : Air Taxi

Make Model Name : Citation Excel (C560XL)



Flight Plan : IFR



Person

Reference : 1



Reporter Organization : Air Taxi





Events




When Detected : Pre-flight



Assessments

Contributing Factors / Situations : Company Policy


Primary Problem : Company Policy

Narrative: 1

The Company routinely flight plans with a planned altitude on a departure fix in order to

account for the higher fuel consumption when departing a satellite airport.

However, when such processes are used in the Company's flight planning it ends up filling

such initial lower altitude as the requested final altitude to ATC. Unfortunately, the FAA's

ATC system does not seem to recognize the subsequent altitude changes included in the

ICAO flight plan.

The issue with such a lower altitude being filed is that it may lead to a different route then

the one that would be received for the higher altitudes. This presents a number of risk

factors -- E.g. Not enough fuel, multiple full route clearance changes, etc.

Today's flight was planned for FL400; however, we were cleared with a planned final

altitude of 16000 FT. Clearance delivery was not able to change the planned altitude and

we had to ask one of the subsequent ARTCC controllers to change the altitude.

Synopsis

Cessna 560XLS Captain reported that the FAA's ATC system does not seem to recognize

the subsequent altitude changes included in the ICAO flight plan.

ACN: 1468112 (15 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ZSPD.Airport


Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZSHA


Make Model Name : B787 Dreamliner Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger


Person

Reference : 1




Function.Flight Crew : Relief Pilot






Events









Assessments




Narrative: 1

I was the [relief pilot] on this flight. Just before the landing, the crew returned from break

we updated weather and everything looked normal for arrival and landing into ZSPD. Once

the landing crew got in their seats, PVG approach started to give us a speed reduction and

then eventually a delay turn to the north. Approach was very vague on the reason other

than traffic. We flew north for some time and queried why. Eventually they turned us back

towards arrival and we were told number 2 for landing and the reason was weather. Our

weather radar wasn't painting anything that caused us concern. Our fuel by this time was

getting close to bingo however we were assured that they will get us right in as we told

approach fuel was critical. Once on the arrival the controller said 35 minute delay. This

was not going to work for us so we told controller we will fly direct to our alternate of

ZZZZ. He gave us a vector that was not direct and held us at a lower altitude. We then

[advised ATC] and flew direct ZZZZ and continued our climb.

This was caused by a communication problem with the controller. It was late into the

arrival before we realized it was a weather delay. The controller did not understand our

fuel situation and continued to lead us on. Even after we [advised them of the severity of

the situation] he tried to vector us and keep us down low. Unacceptable considering our

fuel state. Controllers in Shanghai need to understand how to communicate with English

carriers. The need to be very clear on the reasons for delays and real time expected

delays. Dispatchers can help by being more proactive with information on flow into

Shanghai and expected delays. As we pass the South Korean Peninsula it would be nice to

know how things are looking on the arrival. It's easier to stop in Incheon for fuel than

ZZZZ.

Synopsis

B787 First Officer reported the controllers at ZSPD did not convey the actual delays to be

expected during arrival, and did not expedite a clearance to the alternate after being

advised of the low fuel state.

ACN: 1467190 (16 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight

Aircraft

Reference : X



Make Model Name : Skylark 175



Flight Plan : None

Mission : Personal





Component



Problem : Failed

Person

Reference : 1












Events






Result.Aircraft : Aircraft Damaged

Assessments



Narrative: 1

[We] performed our preflight with no prevalent issues. We had planned to take fuel that

morning so we proceeded to fill the tanks with 7.5 gallons each side of 100LL Avgas to a

total of roughly 46 gallons total, 9 of which are unusable. We got a briefing online from

ForeFlight mobile, no weather hazards besides a few TFRs to the south of our flight path.

Our engine run up went well, magneto checks were good, carburetor check came back

positive, and nothing seemed to be out of the ordinary. All engine gauges were green. Our

flight was direct to ZZZ, with a slight maneuver around the mountains to the WNW. We

were told by Tower to follow the Galaxy jet on a 10 mile final, and we proceeded on course

behind them. About 7 miles out, with carb heat on, descent checklist followed correctly,

and RPM/Mixture accounted for, we had a major loss in RPM indicated on the tachometer.

Figuring it may be too lean of a mix, coming from 9,500 ft cruising altitude, we enriched

our mixture to no avail, the engine continued to lower its performance. At this point, [my

passenger] notified the tower that we had an engine failure with a mayday call. I had

control of the plane [on this leg] and [my passenger] did callouts on the restart checklist,

which yielded some rise in RPMs from 1000 to 2200 when the throttle and starter were

engaged for quite a few times. [My passenger] took controls since he is the registered

owner of the aircraft and I attempted to restart many times as [my passenger] talked to

ATC. The full checklist had been attempted 8 times prior to landing, to no success. About 3

miles out our prop went dead and stopped completely. We fell below the glide path and

realized there is no possibility that we land at ZZZ, so [my passenger] chose the field

about a mile and a half from the airport and proceeded to land the plane in said field with

myself following on controls in case anything were to happen on the landing. We then

stopped the plane where it was found upright in the ditch, shut off all systems to secure

the aircraft and immediately exited the plane. We removed ourselves to a safe distance in

case any hazardous fluids were to escape and cause fire. First responders were there

within 20 minutes of the incident. No harm was done to us and the aircraft had minimal

damage to the engine cowling. There is a possible fuel leak on the right wing that may

have caused fuel starvation.

Synopsis

C175 pilot reported a loss of engine power on final approach led to an off-field landing.

ACN: 1467188 (17 of 50)

Time / Day

Date : 201707


Place



Environment


Aircraft

Reference : X

Aircraft Operator : Air Taxi

Make Model Name : Chancellor 414A / C414



Flight Plan : None

Mission : Passenger

Flight Phase : Parked


Component




Person : 1

Reference : 1







Person : 2

Reference : 2














Events








Assessments



Narrative: 1

The aircraft was fueled by the [airport] FBO. The tanks were checked after and appeared

to contain 100LL. After Takeoff abnormal indications were observed by the pilot flying and

pilot observing. High CHT temps were the main concern. Power was reduced and airspeed

was increased to remedy the problem. There was no change. The pilot observing

requested to see the fuel receipt from the pilot flying. The receipt indicated that the

aircraft was fueled with Jet A. The pilot observing who the more experienced pilot is, was

called for the controls and took over the aircraft. The aircraft was immediately turn

towards [a diversion airport]. Approach was notified. The crew switched to the aux tanks

which contained uncontaminated 100LL. The aircraft safely landed. The crew and

passengers were unharmed.

Narrative: 2


Synopsis

The flight crew of a C-414 reported that the aircraft was fueled using "Jet A" instead of

100 LL fuel.

ACN: 1466184 (18 of 50)

Time / Day

Date : 201707


Place



Environment




Light : Daylight


Aircraft

Reference : X


Make Model Name : Small Transport, Low Wing, 2 Turbojet Eng



Flight Plan : VFR

Mission : Personal



Person

Reference : 1











Events

Anomaly.Ground Excursion : Runway

Anomaly.Ground Event / Encounter : Object

Anomaly.Ground Event / Encounter : Loss Of Aircraft Control



When Detected.Other

Result.General : None Reported / Taken

Assessments



Narrative: 1

Upon landing, the Pilot in Command (PIC) was unable to stop the aircraft on [the] runway.

The aircraft struck a taxiway light, departed the runway and came to a rest on grass on

the west side of the runway. Landing speed was calculated at 109 knots and

approximately 3600 feet of runway. ATIS reported winds at time of arrival were 220 at 10

knots. The PIC declared a low fuel situation with approximately 500 lbs of fuel remaining

and was cleared to land.

Synopsis

A corporate jet First Officer reported a runway excursion when the PIC was unable to stop

the aircraft.

ACN: 1465904 (19 of 50)

Time / Day

Date : 201706


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : Cardinal 177/177RG



Flight Plan : IFR

Mission : Personal




Component




Person

Reference : 1












Events








Assessments



Narrative: 1

Shortly after taking off, while leaning during climb the engine starting running rough. I

noticed that cylinder #2 and #4 had no EGT. Looked up and saw [an airport] about 7

miles ahead and found frequency and [advised ATC] and made a normal straight in

landing. Asked where the maintenance shop was and taxied. Door was locked. Fireman

called mechanic and no one picked up. I called my mechanic and discussed the problem.

This plane 2 years previously had a similar problem and was found to be a clogged fuel

injector. Mechanic asked if I had access to tools. Fireman was able to get access to the

hangar and tools.

My mechanic told me where the fuel injectors were and how to remove them. Found #2

and #4 were partially blocked and I cleaned them with compressed air. Followed

mechanic's instructions to replace the injectors. Started the plane and did a mag check

and found that #2 and #4 were working properly on both mags. Later flew plane to

mechanic. He called Lycoming and felt it best to replace the fuel pump and several

components in the fuel system. He also replaced the fuel injectors with the newer style.

Synopsis

C177RG pilot reported diverting after the engine began running rough. Problem was later

traced to partially clogged fuel injectors in cylinders #2 and #4.

ACN: 1465525 (20 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : PHX.Airport

State Reference : AZ

Environment


Aircraft

Reference : X

ATC / Advisory.Tower : PHX

ATC / Advisory.TRACON : P50


Make Model Name : Widebody Transport



Flight Plan : IFR



Airspace.Class B : PHX

Person

Reference : 1









Events









Assessments



Narrative: 1

On arrival, PHX was experiencing wind-shear and microburst activity and a dust storm was

approaching. On visual approach to runway 7R at PHX wind-shear and microburst alerts

were activating, PIREPs were reporting 20 knot loss of airspeed on final. Elected not to

descend at the VDP, fly straight through initial and avoid wind-shear conditions. WX

Conditions remained over PHX airport and continued to degrade in the surrounding area.

After 20 minutes of vectoring informed PHX Approach control that we will be reaching a

fuel critical / emergency fuel state if not on the ground by then. Flight crew was

coordinating with PHX Tower and Approach control, company dispatcher, PHX Ramp

control, to find the safest place to land. Exercising Captains authority I decided to land

ZZZ, [a nearby airport]. The landing was uneventful, ground support met us and we shut

down, and the fuel system indicted total 10,800 LBS (200 LBS below our emergency fuel

amount). The aircraft was serviced and after the severe weather was no longer a threat

we took off and flew to PHX (10 NM away). All agencies were coordinated with during this

evolution and Duty officer kept apprised of the situation and solicited for advice. Kudos to

PHX approach controllers, Ground Services at ZZZ and my First Officer, who's new to the

company and been on the line for 4months, all did a great job! Emergency was not

declared, as soon a decision was made expeditious traffic handling got us over ZZZ in just

moments.

Weather forecasted other then what was actually encountered upon arrival. Give us more

fuel! Closer monitoring of weather while enroute to destination.

Synopsis

Widebody Captain reported encountering un-forecast wind shear and microburst activity

upon arrival at PHX. After 20 minutes of vectoring the crew elected to divert, landing with

10,800 LBS of fuel.

ACN: 1464115 (21 of 50)

Time / Day

Date : 201707


Place

Locale Reference.Airport : ORD.Airport

State Reference : IL


Environment




Light : Daylight

Aircraft

Reference : X

ATC / Advisory.TRACON : C90


Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR

Mission : Passenger

Nav In Use.Localizer/Glideslope/ILS : Runway 9L


Airspace.Class B : ORD

Person : 1

Reference : 1








Human Factors : Distraction



Person : 2

Reference : 2











Events

Anomaly.Deviation - Altitude : Overshoot






Result.Flight Crew : FLC Overrode Automation


Result.Flight Crew : Regained Aircraft Control


Assessments



Narrative: 1

This event took place on a flight to ORD. The Captain was the PF. We acknowledged

building weather down final when cleared the approach to 9L and switched to tower. We

intercepted the glideslope and, at around 2500 ft MSL, encountered a sudden tailwind.

With AP (autopilot) engaged, the nose pitched down, throttles went to idle, and the jet

was accelerating. The Captain recognized this as a potential microburst situation and

called a go-around. FO called the go-around and tower told us to track the localizer and

maintain 3000 ft MSL. We maintained airspeed, went flaps 15, and maintained 3000 ft.

Tower then directed a left turn to 040, which was a turn into the weather. We delayed the

turn and focused on flying the aircraft, though in the process tracked slightly right of

course to remain clear of the weather. Tower again gave us the left turn to 040 and we

headed that way. Tower then directed a climb to 4000 ft. Some confusion ensued with our

automation during this process, though positive aircraft control was always maintained by

the Captain. HDG SEL would not initially engage, we believe, because the approach was

still armed. Our FDs also did not assist in our climb to 4000 ft because, as memory serves,

our command for VS on the MCP did not take. The Captain hand flew the jet but was

unable to level off at 4000 ft due to a significant updraft. Both crew members repeatedly

acknowledged the impending and actual climb through the assigned altitude and FO

reported a "significant updraft" with ATC. We believe that, at most, the jet reached 5000

ft. ATC responded with a quick, respectful, and deferential "okay," understanding that we

were aviating first. At this point we were indeed still dealing with the effects of the

weather and focused on controlling the aircraft. We finished cleaning up the aircraft and

requested a heading to our divert airport. Either due to yoke inputs while flying through

the weather, or due to automation difficulties, the Captain's AP would not engage for some

time. The Captain told ATC that we were low on fuel and were unwilling "to fly through

that thunderstorm again." After receiving our heading to ZZZ we noticed the Captain's

FMC was frozen. The FO's FMC was functional and we are not sure when the left FMC

froze. Our divert to ZZZ was otherwise uneventful, as was our delayed but successful flight

to ORD later that evening.

We are certain a go-around was the right decision and are happy we kept the jet at a safe

altitude above the ground. We could have performed a cleaner go-around but were

focused on flying the aircraft around the weather and not exceeding any speed limitations.

Our impression was that ATC understood that we were busy dealing with significant

weather. Their "okay" had a tone of deference and understanding, and we doubt they will

mark this as a pilot deviation. In hindsight, we believe the best decision would have been

to not accept the approach clearance and ask for a safe heading away from the weather.

We did not have situational awareness on whether traffic behind us was cleared the ILS to

9L, but we hope not.

Narrative: 2


Synopsis

B737 flight crew reported a windshear encounter while on approach to ORD. They

executed a missed approach and elected to divert due to the weather and their fuel

situation.

ACN: 1463694 (22 of 50)

Time / Day

Date : 201707


Place




Environment



Light : Daylight


Aircraft

Reference : X


Make Model Name : M-7



Flight Plan : None

Mission : Training

Flight Phase : Takeoff


Person

Reference : 1














Events







Assessments



Narrative: 1

I departed with a Switzer 2-33 glider on glider orientation flight in tow. At about 400 feet

the engine lost power, I signaled the glider to release (easily made it back to the runway),

and I quickly sought a place to make an off-airport landing (did not have sufficient altitude

to make it back to airport). I landed in a field of low stubble and soggy grass without

incident. The aircraft did not appear to be damaged. There were no structures on the

ground and no damage/injuries. While there appeared to be more than sufficient fuel for

the flight, fuel starvation made have been the cause for the loss of power.

Synopsis

Glider tow pilot reported a loss of power after takeoff that resulted in an early release of

the glider and an off-field landing.

ACN: 1463585 (23 of 50)

Time / Day

Date : 201707


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : B737-800



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS




Person : 1

Reference : 1










Person : 2

Reference : 2









Events


Anomaly.Deviation - Procedural : Weight And Balance


Anomaly.Deviation - Procedural : MEL







Assessments




Narrative: 1

We departed with a cockpit left main fuel quantity indicator placarded inoperative. Per

MEL, we received a fuel slip which indicated a total fuel load of 18,500 pounds. At lift off

the airplane was right wing heavy and took about one unit of rudder trim to level the

wings in cruise. The left fuel quantity indication decreased reaching zero during cruise at

31,000 feet. Immediately thereafter the left engine started to roll back. We opened the

fuel crossfeed valve and the engine recovered and continued to run. Advised ATC and

requested immediate turn towards ZZZ. Landing was uneventful. Total fuel at shut down

3500 pounds, all of it in the right main tank. Left main tank had no usable fuel remaining

in it; this was determined by sticking the tank.

Contract maintenance, in coordination with Maintenance Control, subsequently placarded

the wing left main fuel quantity indicator (in addition to cockpit left main fuel quantity)

inoperative. After aircraft was refueled and fuel quantity verified by sticking the left main

tank we ferried the aircraft to ZZZ1. The fuel aboard noted on the fuel slip was NOT what

we had aboard the aircraft. Retrain the fueler in the proper procedure for fueling the

aircraft with an inoperative fuel quantity gauge or change the procedure. This is a serious

safety issue and this flight could have had a much worse conclusion.

Callback: 1

The reporter confirmed that the Fueler did not dip the tank as required by the MEL, but

instead used the wing gauge which was not correct.

Narrative: 2

The aircraft logbook indicated that the aircraft had problems with the fuel indicating

system. The left main wing tank indicator was inoperative. Although, the gauge still

indicated a number on its display, the amount of fuel it indicates was considered to be in

error. Following refueling, we received a fuel slip indicating the proper amount of fuel and

reviewed the MEL to ensure the proper procedures were followed in the cockpit. The

aircraft flight release included the citation about the fuel indicator. We believed we had

received the proper fuel and were properly set for flight.

Enroute, about 1 hour into the flight, the left fuel gauge quantity passed "0" pounds

indicated. At that point, the engine continued to operate, indicating that the tank still

contained fuel. However, a few minutes later, the engine RPM began to decay and we felt

a momentary yaw. Captain, sensing that the engine was indeed being starved for fuel,

immediately opened the main tank fuel crossfeed, the engine recovered. Realizing that we

were now in a critical fuel situation (about 4500 lbs remaining), we immediately advised

Center and requested a diversion. We had just flown past ZZZ, it was closer, and we knew

it was VMC at that time. We immediately turned toward ZZZ and performed an uneventful

landing. Our landing fuel state was: Center tank - zero fuel; Left wing tank - zero fuel;

Right wing tank - 3500 lbs. Our planned fuel at landing should have been approximately

4200 lbs in each wing tank for a total of approximately 8200 lbs.

Captain and I believed the fueling process had not been properly conducted, which

resulted in the left tank being shorted approximately 6000 lbs from the desired total of

18000 lbs. There was an error made in fueling the aircraft and the quantity was not

verified before or after the fueling process. Although we trusted that the procedure was

completed properly, it had not been. An aircraft which is known to have fuel indication

problems, should have the fuel 'physically' and 'mathematically' verified. Physically verified

with the fuel tank 'sticks' as well as mathematically through computation from prefueling

state of the aircraft to the final fuel state.

Synopsis

B737 flight crew reported being dispatched with an MEL for a malfunctioning left wing fuel

quantity indicator. During cruise when the gauge showed zero fuel, the engine began to

lose thrust. The crossfeed was opened, the engine recovered, and the flight diverted.

ACN: 1462890 (24 of 50)

Time / Day

Date : 201707


Place

Locale Reference.ATC Facility : ZDV.ARTCC

State Reference : CO

Environment




Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZDV


Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS



Airspace.Class E : ZDV

Person

Reference : 1












Events



Detector.Person : Air Traffic Control



Result.Flight Crew : Returned To Clearance

Result.Flight Crew : FLC complied w / Automation / Advisory



Assessments




Narrative: 1

During our descent into COS the storm cell had moved off the field but ATC informed us

that there was a micro-burst alert and they assigned us to hold at the VOR. We discussed

our plans if we were not able to get into COS. We settled on DEN as a good plan B. As we

held it became apparent that we may not get into COS. I told ATC we'd like to divert to

DEN. They informed us there was now a ground stop into DEN. Since we were holding over

the PUB airport that became the clear alternative. We checked with dispatch and we could

have landed there but there was no fuel available. Our only option then became to [advise

ATC of our fuel situation] so that we could get into DEN. Just as we made the turn to DEN

ATC informed us that the winds appeared to be dying down in COS. We had just enough

fuel to get in so we gave it a try and were able to land without incident. We continued into

COS with the emergency because if we had gone missed we would have had to go direct

to DEN given our fuel situation.

While everything worked ok alright as we held and burned fuel our options especially in

the inter-mountain west became fewer and fewer until we had no choices left except to

[advise ATC of the situation] and head to DEN.

Synopsis

An EMB-145's filed destination closed because of weather and a micro-burst alert so the

crew planned a diversion but were advised of a ground stop. As the crew prepared for a

diversion, their destination airport opened and the crew continued on.

ACN: 1462879 (25 of 50)

Time / Day

Date : 201707


Place




Environment

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS


Route In Use : Oceanic


Person

Reference : 1









Events






Assessments




Narrative: 1

Prior to my flight I was approached by a Check Airman and he told me to pay close

attention to fuel due to the fact that on several flights he and several other pilots

experienced actual Critical Fuel (CF) trending less than flight planned Critical Fuel. I

advised my First Officer of the discussion I had with the Check Airman and we decided to

pay close attention to detail on our fuel burn. At the gate we called fuel at 70,000 lbs.

Ramp fuel on flight plan was 70,166 and minimum release was 67,846. Fuel on Board

(FOB) reduced to 69,822 prior to engine start. Fuel over Destination (FOD) on flight plan

was 19,100. MCDU FOD showed 18,100 prior to engine start. Enroute to ZZZ at top of

climb we noticed that our fuel over destination showed 17,100 and FOB showed 37.2.

Flight plan critical fuel was 37,396. Actual critical fuel was showing less than planned.

We sent an ACARS to dispatch to inform them that we were showing less than critical fuel

on our MCDU than what was reflected on the Flight Plan. Dispatch responded via ACARS

with "copy critical fuel, dispatch." We sent them a second message again and asked them

what plan of action we should take and then we got no response. We decided to SATCOM

Dispatch directly and explained the above scenario. Dispatcher decided to try running

scenarios in his system [to] recover some fuel. He tried removing alternate but it didn't

reduce our planned CF enough to reflect what we were going to have. [He] then took our

actual ZFW which was less than planned and it gave us a new CF of 37,298. It was the

best he could do. It was better than our original on the Flight Plan so he sent us a re-

analysis reflecting our new CF of 37,298.

At that point we improved somewhat on our CF which was 37,200...still close. We decided

to call [a company flight] up ahead of us and asked them what their Critical Fuel Situation

(spread) was and what their winds were at FL410. They said that their CF was fine and

that they had a stronger tailwind of 45 kts versus what we had at our altitude which was

about 28 kts. Big difference and I asked them if we could take their altitude to improve

our fuel and they obliged. We simultaneously asked for our change of altitudes with ATC

and we were granted a climb to FL410 while they descended to FL400. Upon reaching

FL410 our CF estimate improved to 37,300 and finally increased to 37,500.

Looking back and reviewing our Flight Plan had we took off with min take off fuel of

67,846 with our Flight Plan ETP accumulated Fuel Burn of 30,400, that would leave us with

37,446 at ETP which is only 50 lbs more than the Flight Plan CF of 37,396. This fuel

margin is extremely tight. In post-flight discussion with Dispatchers, they advised me that

they are being told to reduce the "fuel margins" and cannot increase them unless the

Captain requests for more fuel.

I think the cause is the pressure put upon the Dispatchers to reduce fuel allowances to

save money. This is now causing greater concern about the SAFETY of our flights

(regarding fuel) and placing a greater burden on our pilots to be insist that the fuel loads

be more scrutinized even more than ever.

Synopsis

A330 Captain on an intercontinental flight reported a low fuel situation developed when

they had less than forecasted tailwinds. Flight requested a higher altitude with better

winds.

ACN: 1462249 (26 of 50)

Time / Day

Date : 201707


Place




Environment

Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Person : 1

Reference : 1











Person : 2

Reference : 2









Person : 3

Reference : 3






Events







Assessments




Narrative: 1

Shortly after leveling off at FL350 we got a fuel imbalance light. Fuel in the right tank was

decreasing way faster than the left tank. We monitored the situation for a few minutes to

confirm this. I opened the crossfeed valve (with the FO concurring) and turned off number

two fuel pumps as the imbalance was increasing very fast and I could see the control

wheel compensating. We read the QRH for a fuel leak. Confirmed there was a leak. Fuel

flows were equal. Appeared that right tank was still using more fuel than the left tank.

Fuel used was equal. QRH directed us to shut down the engine. We decided not to do that.

Main reason for that was that the FAs did not see any fuel leaks anywhere and in my mind

I thought if I had misread the situation I did not want to shut down a perfectly good

engine and make my problems worse. I didn't want to scare Passengers either.

We contacted Dispatcher thru ACARS and then later by radio. We had already started to

divert but coordinated it with Company as we were doing that. We landed without incident

and did not declare an emergency, but ATC knew what our situation was. We had fire

trucks follow us to gate. After sitting for a while and thinking about the situation I was

wondering if I had left the cross feed open when I did my preflight. It would have caused a

fuel imbalance. When we read the checklist and opened the crossfeed we may have closed

it then thinking we had just opened it. We both looked at the switch when I did this but we

may have seen what we wanted to see.

So when we thought we had opened the crossfeed, and running both engines on the left

tank, in reality we may have been running left engine on left tank with boost pumps and

the right engine was suction feeding. So it looked like to us, as crossfeeding on left tank

and the right tank was still losing fuel like crazy. We diverted right away. The only reason I

don't think this is what happened is that I think we would have had a much larger

imbalance with the crossfeed open for the entire climb. Our largest imbalance was 1500

pounds, and we actually started to get our imbalance back slightly after we started to

crossfeed. Also when we parked the aircraft, we both saw me put the crossfeed to close

after I shut down the right engine on taxi.

I know we verified the switch movement but I personally did not watch the blue lights

activate to verify the valve movement. We also watched the switch being moved but

maybe did not really confirm its position. Probably rushed the situation but we thought we

had a really bad leak that was uncontrollable. We may have jumped to a conclusion too

quickly. Could have probably called Maintenance inflight and gotten some guidance.

Narrative: 2


Narrative: 3


Synopsis

B737 flight crew and Dispatcher reported a fuel imbalance at cruise and subsequent

diversion.

ACN: 1461603 (27 of 50)

Time / Day

Date : 201706


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Bonanza 35



Flight Plan : None

Mission : Personal



Component : 1




Component : 2



Person

Reference : 1













Events






Assessments



Primary Problem : Ambiguous

Narrative: 1

Aircraft lost power immediately after takeoff. Aircraft performed normally during the run-

up prior to takeoff. Airplane had just finished a small repair for running rough. Landed in a

recreational complex immediately adjacent to the airport. Normal glide to landing. No

damage and no injury. Towed the aircraft back to the airport for further inspection. Found

debris in the main fuel drain screen and the screen to the injector body.

Learnings: while we did maintenance for running rough we never found a smoking gun to

indicate the issue. Suspected a vapor lock due [to] the heat of the day. After the Engine

cooled down and run-up was normal we assumed we had determined the cause. On

takeoff from the grass runway which was very rough terrain I could not hear the popping

of the engine due to the bumping of the airplane as it accelerated down the runway. As

soon as the wheels were up it was apparent that the engine was running rough and I could

not maintain altitude and elected to land in the recreational field next to the airport.

Conclusions (what I learned from this event). Make sure that the reasons for any aircraft

performance issues is thoroughly discovered. And not to underestimate the terrain used

when taking off after a repair/maintenance. I'm convinced had I used the paved runway

(slight cross wind) I would have heard the engine running rough and aborted the takeoff.

The grass runway was the longer runway and aligned into the wind.

Synopsis

Beechcraft Bonanza pilot reported an off-field landing due to loss of power on takeoff

caused by debris in the fuel system.

ACN: 1461572 (28 of 50)

Time / Day

Date : 201706


Place





Environment



Light : Daylight

Aircraft

Reference : X



Make Model Name : Light Sport Aircraft



Flight Plan : None

Mission : Personal




Component : 1




Component : 2

Aircraft Component : Fuel Line, Fittings, & Connectors


Person

Reference : 1















Events


Anomaly.Deviation - Procedural : Maintenance




Were Passengers Involved In Event : Y





Assessments



Narrative: 1

I departed ZZZ to do sightseeing and my passenger wanted to take photos.

[Approximately 15 minutes after departure] the engine began to run rough. I decided to

return to ZZZ where the aircraft is based. I entered class D airspace around 2,000 feet

MSL originally planning on the left base runway XY. The tower noticed I was unusually

high and they asked if I wanted [a different] runway, which I accepted and was cleared to

land. I did not declare an emergency, however the tower deemed it was an emergency;

crash fire rescue was activated. At approximately 300 feet AGL crossing the runway

threshold the engine failed and the propeller came to a full stop. After landing I attempted

to restart the aircraft, which it did. I taxied the aircraft back to the hangar without

incident. No damage. The aircraft had been returned from maintenance where it

underwent an annual inspection and a 5 year rubber change. Maintenance department is

still investigating.

Callback: 1

Reporter indicated that the left fuel tank supply line and overflow line were found to have

been swapped during the recent maintenance work. The aircraft had been test flown after

the annual, but had only been operated from the right fuel tank. The condition was

reproduced on the ground. The lines were moved to the correct positions and the system

has functioned normally since.

Synopsis

Light sport aircraft pilot reported a rough running engine progressed into an engine failure.

The problem was traced to fuel lines that had been incorrectly installed during recent

maintenance.

ACN: 1459617 (29 of 50)

Time / Day

Date : 201706


Place




Environment



Light : Daylight

Aircraft

Reference : X



Make Model Name : Light Transport, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS






Person : 1

Reference : 1










Person : 2

Reference : 2










Events


Anomaly.Deviation - Track / Heading : All Types





Detector.Person : Air Traffic Control


Result.Flight Crew : FLC complied w / Automation / Advisory



Assessments



Primary Problem : Procedure

Narrative: 1

I am filling out this form due to a possible pilot deviation call we received from ATC on our

change of destination. We were on an IFR flight plan originating from home station. A line

of storms stretching from the [across the coast], was preventing a departure clearance

from clearing us IFR through normal routing to our destination, as all the gates were

closed. We were told the only IFR option was at low altitude.

To make this possible we contacted our flight follower through ARINC and proposed a

flight plan to a mid-Atlantic airport using the escape route and also filed another flight

plan. This was in hopes of flying south to get around the storms to the west and finally

proceeding to our final destination. We were under the impression that this was the only

way to get out of the departure airport without waiting possibly 3-5 hours for the storms

to pass. We were able to pick up the clearance south and flew the escape route and once

we got to the point where there was a gap in the storms (further south) we requested a

change of destination to a Midwest airport.

Center then handed us off to approach who accommodated our request, after first being

assured that we did indeed have a flight plan on file. Approach cleared us through to our

intermediate fuel stop and gave us a climb to FL230. Passing approximately FL200,

Approach informed us Center wouldn't be able to take us and gave us a right 90 degree

turn. Approximately 30 degrees into the turn Approach told us that Center did take the

handoff and turned us back left on course. We were eventually handed off to Center. We

were given a new altitude of FL340 and were climbing from FL230-340 when we received a

call from Center to copy down a number for possible pilot deviation.

We were quite surprised by this call and were in communication with our company aircraft

who had accomplished the same change of destination about 5-10 minutes ahead of us

and had received the same possible deviation call from ATC. They headed on uneventfully

to our destination and we made a fuel stop and then onto our final destination, where we

completed our flying for the day.

Once on the ground, we called ATC on the number, and were told no need for further

explanation, that they were in contact with another pilot on the aircraft ahead of us, who

could explain the issue. We were told by our colleague in the other aircraft that there were

no flight deviations or regulatory breaches but that we had a created an undue workload

and upset the normal operations of Center on a busy day with convective weather

complications.

Narrative: 2


Synopsis

A corporate flight crew reported ATC would not issue an IFR clearance because weather

had closed all desired IFR gateways. The crew elected to deviate and continue, their

actions disrupted ATC operations.

ACN: 1459577 (30 of 50)

Time / Day

Date : 201706


Place




Environment




Light : Daylight


Aircraft

Reference : X



Make Model Name : Duchess 76



Flight Plan : IFR

Mission : Training

Nav In Use.Localizer/Glideslope/ILS : Runway XX




Component

Aircraft Component : Reciprocating Engine Assembly


Problem : Failed

Person

Reference : 1














Analyst Callback : Attempted

Events









Assessments




Narrative: 1

We were being vectored for the ILS. The left tank was showing low, right tank had

considerably more fuel, we decided to cross feed for the left Engine from the right fuel

tank. After being on the localizer approaching final Approach fix the left Engine quit which

caused the plane to roll to the left initially we recovered the aircraft. Tower saw we were

off the localizer and wanted us to go back to Approach, we said we were unable, they

insisted. At that point we felt the best decision for the safety of the aircraft, taking into

consideration warm day density altitude, being in a light twin with not a ton of power to do

a Single Engine climb was to continue straight to the runway because we had ground

contact, broke out of the clouds and could see the airport.

Synopsis

BE76 Safety Pilot reported experiencing an engine failure during an ILS approach.

ACN: 1459305 (31 of 50)

Time / Day

Date : 201706


Place




Environment

Light : Daylight

Aircraft

Reference : X


Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR

Mission : Passenger


Person

Reference : 1











Events




When Detected : Aircraft In Service At Gate


Assessments



Narrative: 1

We were operating the flight after a delay due to weather and crew placement. We had

received an ATC reroute prior to pushback. An ACARS message was sent to Dispatch

informing them of the reroute and we waited at the gate to confirm we had enough fuel

for the new route. Dispatch sent us the new fuel numbers confirming we did not need

additional fuel.

Once we were in line for takeoff, we received an ACARS message from Dispatch saying we

needed to return to the gate and get more fuel. They apparently never read the original

message we sent giving them the new route. While taxiing back to the gate, we shut down

engine 1 in line with company SOPs. Once we parked at the gate, the flight crew became

distracted with other duties such as calling operations, monitoring jet bridge movement,

communicating with the cabin crew and passengers, and coordinating with Dispatch on our

new fuel load. Neither flight crew member called for the parking checklist. This caused the

number 2 engine to never get shut down while parked at the gate. The engine was

running throughout the entire fueling process which is against company SOPs. The flight

crew did not become aware of the issue until we had pushed back from the gate and

started engines.

Once we became aware of the issue we both admitted to the failure of not running the

checklist and becoming too distracted.

Flight crew became distracted when a non-standard event occurred. Had to return to the

gate to load more fuel after Dispatcher became aware of ATC reroute. The flight crew

failed to complete the parking checklist after returning to the gate. Distraction with other

tasks and duties caused the checklist to not be completed.

Don't let yourself become too distracted that you forget to follow normal procedures. If the

Captain doesn't call for a checklist at the appropriate time, prompt him for it. When things

happen outside of the operational norm, don't get dragged down into the weeds without

following normal procedures. Always complete the appropriate checklists even when things

go differently than normal.

Synopsis

EMB-145 First Officer reported the crew failed to shut down Number 2 engine at the gate

while refueling because of distractions and workload.

ACN: 1459271 (32 of 50)

Time / Day

Date : 201706


Place




Environment


Aircraft

Reference : X





Flight Plan : IFR

Mission : Passenger


Component




Person

Reference : 1












Events









Assessments





Narrative: 1

Shortly after arriving at the aircraft a mechanic came to the cockpit and stated they

needed to do some work because the fueler couldn't get the correct amounts in the tanks

due to fuel shutoff valves closing. This isn't unheard of so I was not concerned. After

stepping back to say hi to the flight attendants I saw the mechanics had opened the

equipment access hatch in first class. This I have never seen before to work a fuel transfer

issue, but again I wasn't concerned.

Shortly afterwards the fuel issue was resolved and the fuel sheet was brought to the

cockpit. At this point I noticed the fuel load of Left 63.1 Center 118.0 Right 63.1. I took

note of it because it was exact (left and right) this is unusual but good, I thought to myself

the mechanics did a perfect job!

About 45 minutes later when preparing for the before push checklist I noticed the fuel was

now 2000 lbs lower in the left tank and 2000 lbs higher in the center tank. Also after my

before push flow the center right fuel pump should have load shed but this time it didn't.

Right away I thought something in the fuel system is still set to transfer fuel or was left

"connected" between the left main and the center tank.

After having maintenance come back out to the aircraft they looked the plane over made

some adjustments (I am not sure what exactly they did) the fuel was again balanced and

the center right fuel pump now load shed like it should.

At this point we believed the issue was corrected. We then taxied for takeoff. After takeoff

when passing 10,000 an IRO (International Relief Officer) asked what was happening with

the fuel. We brought the fuel synoptic up and shockingly the left tank was now 3000 lbs

higher than it was at the gate.

We decided the best course of action was to get up to altitude before an in-depth

discussion. After getting close to cruise the Captain called Dispatch and [Maintenance] on

the satellite phone and I was in charge of flying and talking to ATC. The Captain, with

input from the IROs, Dispatch, and [Maintenance] attempted to understand and remedy

the situation. After quite a while it became apparent that none of the crew was

comfortable taking the aircraft over the Pacific Ocean like it was.

We elected to return to [departure airport] for further maintenance work. The crew was

also not comfortable jettisoning fuel which would open more valves and further complicate

what we considered an "unknown" fuel system. By now we had the system burning out of

the center tank and decided to use delaying vectors altitude and landing gear to increase

our burn to a weight we were comfortable with.

After arriving at that weight we conducted the arrival and made an uneventful overweight

landing.

Synopsis

B777 First Officer reported returning to departure airport after experiencing fuel system

anomalies.

ACN: 1458556 (33 of 50)

Time / Day

Date : 201706


Place

Locale Reference.Airport : ZZZZ.Airport


Environment



Light : Night

Aircraft

Reference : X


Make Model Name : B747-800 Advanced





Person : 1

Reference : 1





Function.Flight Crew : Check Pilot






Person : 2

Reference : 2










Person : 3

Reference : 3








Events








Result.Flight Crew : Returned To Clearance



Assessments




Narrative: 1

Upon reaching our destination airspace at approximately XA35, ATC asked us to hold 70

miles from ZZZ VOR due to large thunderstorms over the airport. Several other aircraft

destined for [the] airport were also holding. ATC made it clear that no aircraft were being

permitted to make an approach to the airport and would not provide any EFC times.

After entering holding, I calculated a "bingo fuel" (minimum fuel at which I would no

longer tolerate holding and would proceed to our designated alternate) of 20.5 metric

tons. This "bingo fuel" was the sum of 13.3 tons of fuel to fly 1 hour and five minutes to

Ahmedabad and additional 7.2 tons of fuel in reserve. This would allow us to fly to the

alternate, make an approach, go missed approach--returning to the radar pattern--then fly

one more instrument approach and safely land.

As time passed while we held as directed, other aircraft expressed their concern to ATC

regarding their limited fuel quantity. A couple of other aircraft began to divert to their

designated alternates. At approximately XA45, I called approach two or three times to tell

them we would have to divert to our alternate soon due to the lack of fuel onboard. The

controller did not answer any of my calls. In my opinion, the controller had become

overwhelmed with the number of aircraft requesting to divert to their alternates.

At XA48 with 21.8 tons of fuel and with no indication that the weather would clear over the

airport in a timely manner, I asked approach control to give us vectors to our alternate.

Even after asking three or four times, the controller did not acknowledge any of my

requests. At approximately XA50, I elected to proceed to the alternate. Even after the ATC

controller did not reply to my calls.

Shortly after stating "fuel emergency" several times, I transmitted that we were leaving

holding and proceeding to [alternate] airport by way of ZZZZZ1 fix at our present flight

level. Even then, the ATC controller did not respond. At this point, we looked up other

frequencies and attempted to contact air traffic control for assistance. At approximately

XA57, we received a voice request over guard frequency (121.5) asking us to return to our

previous controllers frequency. We did so and the controller asked if we would like a

higher altitude to proceed to our alternate. I requested flight level 320 and we were given

flight level 300. It seemed to me as if it was now a different controller on duty, as the

voice was not the same as the original controller.

At approximately XB13, the controller told us that airport was now open and accepting

approaches and was asking if we wanted to return to land. I replied that this would be

acceptable, providing we would not be holding prior to landing. With 16.7 tons of fuel

remaining, we decided it would be safe to return to [original destination].

Although approach gave us extended vectors north of the airport, our approach and

landing was uneventful. We landed with approximately 12.1 tons of fuel as opposed to our

planned landing fuel of 21.9 tons, a difference of 9.8 tons. Our total flight time was 5

hours 52 minutes, as opposed to the scheduled flight time of 4 hours 51 minutes, making

our flight time an additional one hour and one minute more than scheduled.

Narrative: 2


Narrative: 3


Synopsis

B747 flight crew reported being issued a hold without EFC time due to weather.

ACN: 1458298 (34 of 50)

Time / Day

Date : 201706


Place



Relative Position.Angle.Radial : 05


Environment



Light : Daylight

Ceiling : CLR

Aircraft

Reference : X


Make Model Name : Skylane 182/RG Turbo Skylane/RG



Flight Plan : VFR

Mission : Personal




Component

Aircraft Component : Fuel Distribution System



Person

Reference : 1













Events







Assessments




Narrative: 1

Half way through the trip I switched the fuel selector from "both" tanks to the "right" tank

as the left side burns off faster than the right. Later, setting up for my descent, I switched

the fuel selector back to what I believed was "both", retarded the throttle and started my

descent. Approximately half way through my descent I went to add power to level off a

little, discovered the engine did not respond and I had no power. I trimmed the plane to

80 mph (IAS) for max glide and started to go through mental checklist-carb heat, fuel,

mixture, gauges, prop, throttle, ignition. No response. I did this a number of times while

checking airspeed and looking for possible landing sites in between. It became apparent I

would not be able to make an airport so I started to look more earnestly for a landing

location. There was a county road that was a possible option. The surrounding terrain was

extremely rough. As I got closer to the ground I saw that there was no oncoming traffic on

the road in the direction I would be landing and what little traffic was coming up the road

in the direction of landing would be well behind me and no factor so I elected to land on

the road. I landed and coasted the aircraft off the side of the road to make sure I was out

of the way of any traffic.

The problem arose because I had inadvertently switched the fuel selector from "right" tank

to "off" instead of "both" before initiating descent. Because I throttled back for descent

right after switching the selector I did not feel the engine eventually starve and everything

felt normal until I went to add power. In retrospect I made the same error several times in

a row that should have resolved the problem. Mentally when I moved my hand down each

time to check the fuel selector switch in the restart procedure I did not physically touch it

and confirm. Instead in the stress of the situation, I moved my hand toward it, looked and

saw it in vertical position and mentally saw what I thought I should see because in my

mind I had just switched the selector to "both" a few minutes prior. It wasn't until I was in

the final moments of landing the airplane that I realized my error but was too close to

touchdown to take my concentration off the landing and attempt to reposition the selector.

Human Performance Considerations:

After a 20 year hiatus from flying I recently purchased the 182 I was piloting to get back

into flying. I took approximately 10 hours of flight instruction/re-training in the plane prior

to getting signed off and taking the plane out on my own. Though fuel management was

discussed during the re-training process, there was never any need to switch tanks at

anytime as the instruction took place relatively close to the airport. Though this experience

will forever burn into my memory the necessity of visually and physically confirming the

location of the fuel selector, I'm incorporating and reinforcing preventative actions to make

sure this situation never occurs again. 1) Though I took about an hour to sit in the plane

and go through the instrumentation, radio/nav settings and mentally walk through my

flight, I did not think about the process of changing tanks during flight and

mentally/physically walk myself through it. That will now be a mandatory part of my

preflight process. 2) Also to help reinforce the positions of the fuel selector, I plan to put a

florescent green dot on the point of the fuel selector and above "both" and florescent red

dot below the "off" to make settings more visually obvious (if allowable). I will also make

sure when I switch tanks or go through any procedure involving the fuel selector that I

physically touch and visually confirm the position of the switch as instructed.

Synopsis

Cessna 182 pilot reported landing on a country road due to inadvertently selecting the

"off" position with the fuel selector valve.

ACN: 1458248 (35 of 50)

Time / Day

Date : 201706


Place



Environment



Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Person : 1

Reference : 1










Communication Breakdown.Party2 : Dispatch

Person : 2

Reference : 2











Events








Assessments





Narrative: 1

During descent into ZZZ, ATC directed us to hold for unforecast weather overhead the

airfield. We slowed to green dot to conserve fuel. Scheduled on deck fuel was 11.3 and we

were getting close to that limit without the hold so we sent message to Dispatch via

ACARS for options and fuel numbers. No reply was received. Just prior to reaching holding,

ATC informed us the field was now open and landing in the opposite direction from original

flight plan which made fuel even more critical. During vectors to new arrival, we were

given new holding instructions and advised the airport was not accepting traffic and was

unsure of when it would be open again. At this point, we called up the nearest airports on

the FMS and saw ZZZ1 was the closest. After checking the weather for ZZZ1 (reported as

VMC) while in holding, we elected to proceed to the divert prior to completing one turn in

holding. Landed in ZZZ1 with 7.2. Visual approach and landing to runway 29 was

uneventful. During divert to ZZZ1, 3 diversion reports were sent through ACARS and no

reply from Dispatch was ever received. During initial descent into ZZZ, there was not

enough time/fuel to contact Dispatch via Radio.

Cause - Unforecast weather combined with minimum FOD planning left us with few options

when faced with unexpected holding.

Suggestions - 3000 extra pounds of gas would have allowed us to hold longer and given us

more options.

Narrative: 2


Synopsis

A300 flight crew reported diverting due to unforecast weather combined with inadequate

fuel on board.

ACN: 1457646 (36 of 50)

Time / Day

Date : 201706


Place




Environment



Light : Daylight


Aircraft : 1

Reference : X



Make Model Name : Cessna 162 Skycatcher



Flight Plan : None

Mission : Training


Aircraft : 2

Reference : Y



Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior



Mission : Training


Component




Person : 1

Reference : 1




















Person : 2

Reference : 2

Location Of Person.Aircraft : Y













Events

Anomaly.Conflict : Ground Conflict, Critical




Miss Distance.Horizontal : 5

Miss Distance.Vertical : 0

When Detected : Taxi




Assessments





Narrative: 1

On this day my student and I were working on takeoffs and landing. We were in the traffic

pattern for about 30 minutes when one plane starting taxiing to the run-up area, a Cirrus

(SR22). Another airplane was taxiing from the east ramp to the hold-short line of runway

XX, it was an experimental airplane. There was one airplane that took off when we were

turning left downwind to left base runway XX, it was a low wing aircraft. When we turned

final for runway XX the Cirrus was doing the run-up, the experimental was holding short of

runway XX, and the other aircraft that departed runway XX was not insight. We were

approaching runway XX and everything seems to be okay. We were on short final and my

student started his flare, about 5-10 feet from the runway we realized there was another

aircraft coming from the opposite direction of the runway. At that point we were already

touching down so I took the controls as fast as I could and just moved the airplane to the

right because I saw the other airplane moving to the left. Once we passed each other I

said on the CTAF: "What was that about?" No response for about 30-40 seconds and then

a guy said: "Sorry, we got an engine failure". I wasn't very sure what happened because

the aircraft was taxiing like a normal airplane and the engine was running. There was no

injuries or damage to any of the airplanes. I told my student that it was enough practice

for today so we taxied to the ramp and parked the airplane. We talked to the FBO line

guys about what happened and one them said that one of the guys in the airplane said

they had an engine failure so I asked: "how is that possible if they were taxiing with the

engine running" but the line guy didn't know the answer. No further action was taken.

Narrative: 2

I was approaching my destination to land and the engine sputtered. It was determined

that fuel starvation was taking place. Initiated approach to land immediately. Took

corrective action by switching tanks. Advised CTAF traffic for straight in landing due to

emergency. Due to the nature of the emergency selected wrong frequency and proceeded

to land. After landing there was another aircraft about to takeoff and both aircraft veered

to the right of each other. There was no physical contact or damage to the aircraft

involved.

Synopsis

C162 instructor and PA28 pilot reported both aircraft landed on the runway in opposite

directions at the same time. The aircraft both veered to the side to avoid a collision. The

PA28 pilot reported the engine failed and he used the wrong CTAF frequency.

ACN: 1457490 (37 of 50)

Time / Day

Date : 201706


Place

Locale Reference.Airport : EWR.Airport

State Reference : NJ


Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZNY


Make Model Name : Embraer Jet Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger


Flight Phase : Taxi

Airspace.Class E : ZNY

Person

Reference : 1












Events










Assessments





Narrative: 1

Prior to pushback, as is normal procedure, the clearance for our flight was obtained from

Clearance Delivery. Our initial clearance was to expect our filed altitude of FL300. During

taxi out, Newark ground control asked us to contact clearance delivery for a new routing.

We were on taxiway Bravo holding short of Golf with brakes set. The first officer contacted

Clearance Delivery and I, the PIC, monitored as well as copied the new routing as did the

first officer. There was no mention of any altitude changes for our new route of flight

mentioned. Once the clearance was confirmed, the first officer and I worked together to

verify the route and input into the FMS. The new route was checked for accuracy, time,

distance and fuel. The new route appeared to slightly improve our time, distance and fuel

performance upon arrival at destination as compared to the original routing. The first

officer and I agreed on the new routing and advised ground control. Once we departed, we

were cleared to level off at 6000 ft. After a few minutes time, we began to inquire with

ATC about when we could expect higher. ATC advised us that 6000 ft would be our final

altitude. We further inquired and were informed that we had accepted clearance for a

"Sermon South" route and would not be given higher. They also informed us that our

company had agreed to use "Sermon South" routes which is why we were assigned the

clearance. The first officer nor I had ever heard of "Sermon South" routes and were

perplexed by this.

Newark Clearance Delivery had never made and mention of a "Sermon South" route nor

the fact that we would be required to maintain 6000 ft for the majority of the cleared

route. Prior to takeoff and up until we were notified of the "Sermon South" routes, both

the first officer and I believed we would be cleared to our filed flight plan altitude of FL300

(as per the initial clearance) and had no indication from anyone that our final altitude

would be limited to 6000 ft. I immediately began making fuel calculations and

communicating with Dispatch about our situation. I also advised ATC of the fact that if we

were limited to 6000 ft, we would not have enough fuel to legally make it to the

destination and we would be diverting. ATC did attempt to make some concessions and

eventually cleared us to 16000 feet, then to FL200. Even with the higher altitudes, the

calculations revealed that we had consumed too much fuel at the lower altitudes for us to

safely proceed to destination. Dispatch and I agreed to divert the flight to refuel.

Newark Clearance Delivery was under high pressure to re-route numerous aircraft and

may have inadvertently omitted the fact that they were clearing us for a route at 6000 ft.

It is imperative to advise the crew of a turbojet aircraft that they are being re-routed to a

significantly lower altitude than originally cleared for as fuel consumption rates at 6000 ft

are significantly different than at FL300. Additionally, if those routed are to be used, there

should be some sort of education granted to pilots who will be operating them prior to

assigning the routes. Lastly, in the future, when I receive such a large re-route, I will also

confer with dispatch prior to departure to ensure an incident like this is not repeated.

Synopsis

ERJ Captain reported receiving a reroute prior to departure from EWR which appeared

shorter than the original route. Once airborne the crew learned of an altitude restriction

that consumed additional fuel, resulting in a diversion.

ACN: 1456951 (38 of 50)

Time / Day

Date : 201705


Place




Environment




Light : Daylight


Aircraft

Reference : X


Make Model Name : PA-25 Pawnee


Flight Plan : None

Mission : Personal



Component




Person

Reference : 1









Experience.Flight Crew.Last 90 Days : 1.5





Events







Assessments




Narrative: 1

The Piper Pawnee PA-25-235 was being used as a tow plane in glider operations. A

Schweitzer 2-33 glider was in tow when the tow plane lost power approximately 100 feet

off the ground. The glider was released and both the tow plane and glider landed on the

far end of the runway with no damage. This particular PA-25-235 has been modified for

towing operations with a hopper fuel tank. Upon stopping the plane and further

investigation, I noted 85%+ fuel in the plane. When I opened the fuel tank cap, the fuel

tank popped up/out approximately 1". After further investigation, the fuel vent line was

completely plugged and had caused a complete vacuum in the fuel system. I have no

knowledge of a proper vent cover on this Pawnee and it has been flying for years from

what I can tell with no vent tube cover. I hope by filing this report that other owners of

PA-25-235 with modified hopper fuel tanks ensure that they are using fuel vent tube

covers. This was the 5th flight of the day in this plane and this is a particularly difficult if

not impossible item to pre-flight.

Synopsis

PA-25 pilot reported the aircraft lost power at 100 FT AGL when the fuel vent line became

clogged.

ACN: 1456611 (39 of 50)

Time / Day

Date : 201706


Place




Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : Texan T6/Harvard (Antique)



Flight Plan : None

Mission : Personal




Person

Reference : 1












Events






Assessments



Narrative: 1

The day started by topping off fuel. Capacity is 110 gallons. Took off and flew direct to

ZZZ. Dropped off the owner of the plane at ZZZ and then flew from ZZZ toward ZZZZZ

Intersection. Once clear of Class B airspace I flew direct to ZZZ1. Approximately 30

minutes into the flight the engine quit and the fuel pressure light came on. I wobbled the

emergency pump but had little success. A large corn field was ahead and left and I made a

pattern to land there. This type of plane is landed gear up if off airport and no hard

surface. I approached the field at 90 kts and made a couple S turns to lose altitude. Once

closer I noticed the field sloped downhill. The adjacent field was chosen to land in and it

was straight ahead after a low area with overgrowth and a dirt road. I flew the profile of

the first field to maintain speed and aimed for the start of the second field. Once the plane

hit it slid for 250 ft. There was no injuries and no fire.

The remaining fuel was drained from the tanks and verified the tanks did not have enough

fuel to keep the engine running. The total time from the departure airport to the field was

2.7 flight hrs. I normally use 30 GPH to plan. With that I should have had some reserve

once at ZZZ1. In hindsight I should have refueled at ZZZ. In the future I will limit time to

2 hrs between fueling. I also feel that there could have been a loose fuel cap causing

venting of fuel or the aircraft was tilted during fueling causing a lower amount of fuel to go

into tanks. Once the plane is repaired the owner will drain the tanks and check the

capacity by filling.

Synopsis

T6 Texan pilot reported an off airport landing due to fuel starvation.

ACN: 1454793 (40 of 50)

Time / Day

Date : 201706


Place

Locale Reference.Airport : PGD.Airport

State Reference : FL

Environment





Light : Daylight


Aircraft

Reference : X

ATC / Advisory.TRACON : RSW





Flight Plan : IFR

Mission : Passenger



Airspace.Class D : PGD

Airspace.Class E : RSW

Person : 1

Reference : 1










Person : 2

Reference : 2








Events











Assessments




Narrative: 1

Due to partial system wide ACARS failure the ATC Coordinator notified me that my FLL

flight was holding south of RSW due to line of thunderstorms between RSW and FLL, the

destination of the flight. I sent the flight updated RSW weather. I asked the crew, through

an ACARS message of "any chance of MIA?" RSW reported 1 1/4 VCTS PLUSRA, I asked

the crew through an ACARS message to verify fuel on board to possibly change alternate

to TPA. I was shortly notified by the captain that he was on the ground in PGD (Punta

Gorda, FL). He arrived with 3000 lbs of fuel on board. Flight landed safely. Following the

Dispatch Procedure Manual for Off-line Fueling and provided airport plates to crew for

PGD. I built a flight release in accordance with FM for Departure from an Alternate Airport

and emailed the Flight documents to the FBO handling the flight.

All computer programs showed the flight was on the ground in RSW and I called station to

verify. The station agent notified me flight was not there. The computers could not

recognize PGD and the programs showed the flight in RSW. This led to confusion with in

Operations which was rectified shortly after notification.

Narrative: 2

A serious weather event was occurring in south Florida. ATC changed the arrival to FLL 3

times, eventually taking us out over the Bahamas. Numerous airplanes were in the line for

both MIA and FLL. We were being vectored number 1 for the approach to FLL when a

tornado was reported on the field at FLL. Diverted to RSW. Moderate convective activity

was also in the RSW area. We were #2 for the approach when the aircraft in front of us

executed a go around due to a 20 knot loss on short final due to windshear. ATC advised

us that PDG airport was approximately 30 miles north of RSW. The reported wx was

approximately 1700 overcast with 7 miles visibility. We diverted with approximately 6400

lbs on the fuel at that time. We were still deviating for convective activity between RSW

and PDG. We were vectored for a downwind for Runway 22 and cleared to descend to

1500 ft to enable us to see the runway. We then executed a visual approach and landed

with 3200 on fuel. This was a serious wx event in south Florida, resulting in numerous

aircraft diverting for fuel issues. Numerous flight cancellations should have occurred to

prevent this event.

Synopsis

B737 Captain and Dispatcher reported serious weather that resulted in a diversion to an

offline airport.

ACN: 1454326 (41 of 50)

Time / Day

Date : 201706


Place




Environment



Light : Dusk

Aircraft

Reference : X



Make Model Name : Cessna Stationair/Turbo Stationair 6



Flight Plan : VFR

Mission : Passenger




Component : 1



Problem : Failed

Component : 2

Aircraft Component : Fuel Selector



Person

Reference : 1














Human Factors : Fatigue

Events








Assessments



Narrative: 1

Approximately 15 minutes after leveling off at a cruising altitude of 4,500 MSL, the engine

began to surge as it lost all power. Attempted Restart - I immediately flipped on the fuel

boost pump to the "High" position (i.e. pushed both red & yellow fuel pump switches). The

engine increased RPM momentarily and surged a little and made a few popping noises -

then went idle. The prop continued windmilling. Proceeded towards nearest airport - As

the airplane began experiencing a partial loss of power, I pointed the airplane directly

towards the [nearest] airport and began increasing pitch to climb and establish best glide

airspeed. It soon became apparent that the airplane had lost all power and I was not able

to make it to [the nearest airport]. Picked nearest suitable landing area - an open field.

I switched to 121.5 and communicated "total engine failure, anybody copy?" An airline

pilot came on the frequency and requested more [details]. I recognized that this

conversation was quickly turning into a distraction as I tried to process his request, and

ceased communications. Prepared cabin for forced landing - I turned around and told

passengers "Put your hands underneath your knees and lean forward into your seatbelts".

I reached for the fuel selector to turn it "OFF" and it was at this point that I discovered the

true nature of the problem - the fuel selector was already in the "OFF" position. I was now

passing through 2,000 MSL (about 1,000-1,500 AGL). I immediately switched to the Right

Fuel tank, and, within moments, the engine came back to full power. Follow up

communication on 121.5 - I reported on 121.5 that the engine was now back to life. The

airline pilot (do not remember the call sign) came back with a request [from] Center about

the nature of the problem. I told him the fuel selector had been switched off and that

switching back had restored power.

As I reflect on this incident there are 2 basic questions which need to be addressed.

1) How did the fuel selector get switched to "off"? I had reached for the fuel selector to

select the opposite tank (which would have been the LEFT tank in this case) shortly after

level off which is a standard procedure I follow. I believe I selected "OFF" without

recognizing it. Pilot fatigue was one primary issue. The previous weeks leading up to this

event had been extremely busy - I had very little time for rest. The flight was taking place

at the end of a very long day. Throughout the flight, I was not as alert and did not respond

as accurately to the situation as I normally train for - I overlooked the fuel selector during

my initial restart which is normally the first lever that I reach for. Getting distracted from

managing the airplane was another significant factor. I became engaged in conversations

which were gradually consuming more and more of my attention.

2) Why did I not immediately check the fuel selector during my initial restart? Resignation

also crept in during this event. In my 3,700 hours of flying, I have not had one unexpected

power loss in flight (other than occasional, mild carburetor ice issues in a Cessna 150).

The moment it started to happen, I felt myself resigning to the fact that the engine had

suffered a catastrophic failure and I proceeded to handle the situation in that frame of

mind.

Concluding remarks: What made ultimately made the difference in this event was altitude.

The winds in this event favored a lower cruising altitude. However, as a rule, when I carry

passengers I usually go as high as I comfortably can. It's how I was trained. One of my

initial instructors would always say "if there's one thing you can't use, it's the altitude

above you." That thought has always stuck with me, and I'm glad I didn't find myself

flying low and "enjoying the view" when this happened.

Synopsis

C206 pilot reported he mistakenly positioned the fuel selector to "off" resulting in a loss of

power in flight until he repositioned the selector.

ACN: 1454161 (42 of 50)

Time / Day

Date : 201706


Place



Aircraft

Reference : X



Make Model Name : B767-300 and 300 ER



Flight Plan : IFR

Mission : Passenger



Component




Person

Reference : 1





Function.Flight Crew : Check Pilot



Events






Assessments



Narrative: 1

Prior to Equal Time Point (ETP) we had about a 1,200 pound fuel imbalance, right side low,

so we cross fed. Then shortly after that we noticed that the right side was getting low

again. About 2 minutes prior to ETP we got the FMC message, FUEL QTY ERROR-PROG 2

[and] we noticed the difference between totalizer and calculated on the FMC was about

3,000 LBS which happened really fast. QRH has you go to the ENGINE FUEL LEAK

checklist. Part of this checklist states, if you have a fuel imbalance of 1,000 pounds or

more within a 30 minute time frame, you should assume that you have a leak and you

should shut down that engine. We had 800 pounds in 30 minutes. I had [the First Officer]

go back to see if he could see a leak, he said maybe a little mist, but couldn't tell if it was

just a faint contrail, he said other side looked about the same. The imbalance stabilized at

around 1,500 to 1,700 pounds and fuel at destination continued to show 16.3. Fuel

remaining was decreasing also, but not real dramatically. At our last waypoint we were -

1.8. We started our descent into [destination], and while descending, the imbalance

started to increase again, the difference was about 3,200 pounds at one point.

Right after parking and shutting down the engines, the flight attendant called to tell us

that there was a heavy fuel smell coming from the back. Maintenance came up to the

cockpit and told us that there was a bunch of fuel coming out of our right engine. We went

down to take a look and one of the ramp guys came over to tell us that as we were taxiing

in, he noticed a bunch of liquid coming from our right engine, but thought it just might be

condensation. He said the fuel leak stopped once we shut the engine down. Fuel leak, right

engine.

Synopsis

B767-300 Captain reported a fuel imbalance and FMC message FUEL QTY ERROR-PROG 2

on a trans-oceanic flight. After parking at the gate, ramp personnel reported a significant

fuel leak from the right engine.

ACN: 1453572 (43 of 50)

Time / Day

Date : 201706


Place




Environment


Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Person

Reference : 1











Communication Breakdown.Party1 : Flight Attendant


Events




Detector.Person : Flight Attendant





Assessments

Contributing Factors / Situations : Airspace Structure



Primary Problem : Procedure

Narrative: 1

Dispatched well to [the destination], planned landing fuel 1:25. [Destination] VFR, smooth

rides, and no enroute weather forecast. Early unforecast deviation around weather, eight

minute vector around military airspace (there is a vague NOTAM about this requiring

checking a web site to see if it is applicable) and another weather deviation left us with

about 1:15 in landing fuel. The fuel topic was discussed at each crew changeover and we

were all well aware of the issue and not concerned.

There had been an ongoing cabin light issue in which rows of reading and call lights were

turning on randomly and staying on. We contacted dispatch and [maintenance] about this

and their suggestions failed to help. We also had a random cockpit PA issue in which we

sometimes had to reset the cockpit handset to make a PA announcement. About two thirds

of the way through the flight, I made a seat belt PA and everything reset (PA and cabin

and reading lights) and worked the rest of the flight. I waited until the descent (after my

break and after the approach briefing and approach descent checklist) to sort everything

out and try to make a maintenance write up. The write up took three pages of log entries

and they all came back as incorrect (I had put too many characters in the log item field).

Instead of rewriting them (due to time constraints), I called dispatch and had him patch

me through to [maintenance] and I described the situation to him. All of this was complete

by around 15,000 feet, but I had been out of the loop for a while.

[ATC] had started our descent early and we received an insufficient fuel EICAS. We reset

the warning fuel on the performance page to 1 hour of fuel (13,300 lbs). We received

another early descent and the insufficient fuel EICAS came back. We did the ECL

(Electronic Checklist) for that EICAS. At that point someone in front of us received a

holding clearance. We investigated weather and discussed diverting. We were given a

holding clearance without an EFC (Expected Further Clearance) time. We queried [ATC] for

an EFC, they said the airport was changing runways and they did not have an EFC. I have

always been taught that a minimum fuel advisory was not understood at international

destinations and therefore did not declare minimum fuel. We immediately requested a

diversion. We were given a hold for [the diversion airport] also. I might add that the PM

(Pilot Monitoring) was focused on flying the aircraft and did an excellent job. The two non-

flying copilots were very much in the loop and focused on pitching in where they could. I

stated that we were unable holding. Rather than waiting until we were at a landing fuel of

30 minutes or less, I decided it was better to declare the [situation] early and continue

towards a runway. After declaring controllers handled the situation very well. We were

vectored to and landed uneventfully with one hour of fuel remaining, 13,300 pounds.

The entire event from 15,000 feet down to landing was extremely busy. We changed the

destination in the FMC twice, we sent two diversion messages to dispatch. We did not have

time to discuss anything with dispatch after calling about the maintenance issues. I did

follow up with a call to dispatch from the hotel to explain. All checklists were completed

and we handled the situation without any deviations from SOP. I am quite proud of the

way the crew responded to everything that was thrown at us.

There are several items that were learned throughout this event. First and foremost, the

system works. I was asked if I would increase fuel loads from this point on and my answer

is no. From now on, my plan is to take a reasonable fuel load and realize that I can (in

spite of my previous understanding) declare minimum fuel when my landing fuel

approaches one hour of fuel (several aircraft declared minimum fuel after we [advised

ATC] and [ATC] understood and accommodated them), and as a last resort, I can [advise

ATC] approaching 45 minutes of landing fuel and the path is cleared for us to make a safe,

uneventful landing.

I learned to postpone complex write ups and patches to [maintenance] until I am on the

ground instead of in the descent. I knew to leave the ADIRU (Air Data Inertial Reference

Unit) on when we need ACARS on the ground, but did not realize that the ACARS would

have made life easier on the ground.

Training center and most real life diversion scenarios include bad weather and therefore

lots of hold fuel, many distant alternates and therefore lots of time to sit in a holding

pattern and discuss options as a crew and with dispatch. I learned that this scenario, with

VFR weather and minimum dispatched fuel can turn south very quickly. Actions need to be

quick and decisive, CRM (Cockpit Resource Management) needs to be quick as well. We do

not get as much (or any) training for a diversion scenario without lots of time to discuss

options. This is something everyone might want to think through on the ground, if they

have not already.

Synopsis

Boeing 777 Captain reported a fuel critical situation during descent due to unforeseen

deviations.

ACN: 1453554 (44 of 50)

Time / Day

Date : 201706

Place

Locale Reference.Airport : RJAA.Airport



Environment


Aircraft

Reference : X

ATC / Advisory.Center : RJJJ





Flight Plan : IFR

Mission : Passenger


Route In Use.STAR : ELGAR

Person

Reference : 1










Events








Assessments






Narrative: 1

Captain signed for flight plan with landing fuel of 18,100 lbs. No significant weather

planned departure, enroute or destination. No significant maintenance issues. Flight was

flown as planned with the exception of 2 deviations for unforcasted convective areas and a

vector around military airspace in PAZA.

Flight arrived at top of descent with a negative fuel score of 2.0. After normal early

descent (ELGAR arrival via MELON) and vectoring off arrival, several flights ahead on

arrival received holding instructions and were informed RJAA was changing runways. The

flights were given expected clearance times which, if similar for our flight, would result in

landing with emergency fuel. When our flight was given holding instructions we informed

ATC we were unable to accept holding for fuel. After ATC again gave holding instructions

we informed them we needed to divert for fuel. We were given a vector for ZZZZ and

proceeded to plan for diversion. Dispatcher was notified but not consulted due to time

constraints. ATC subsequently informed us that there would be holding for arrival into

ZZZZ due to coordination. We requested clearance for landing at RJAA or ZZZZ whichever

could be coordinated soonest. Uneventful approach and landing were made at RJAA.

Landing fuel was 13,000 lbs.

Synopsis

B777 First Officer reported multiple deviations and delays in flight resulted in the aircraft

landing with emergency fuel.

ACN: 1452522 (45 of 50)

Time / Day

Date : 201705


Place




Environment



Light : Daylight


Aircraft

Reference : X






Flight Plan : IFR






Component

Aircraft Component : Cargo Compartment Fire/Overheat Warning



Person : 1

Reference : 1












Person : 2

Reference : 2












Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor







Assessments



Narrative: 1

Climbing out of 12,000 to 23,000 I (monitoring pilot) heard a sound like a CB popping. I

looked up and noticed "MAIN CABIN SMOKE" light on the overhead panel, I informed the

First Officer (fly pilot) and directed him to level off while I talked with ATC and called the

dead heading pilot (aircraft qualified) up to the cockpit. I asked dead heading crew

member to look in the main cargo area for smoke or fire he grabbed portable O2 bottle

and went downstairs. While rider was checking, the First Officer (FO) turned back and I

talked with ATC. When jump seat pilot returned reporting no smoke or fire visible we

(jump seat pilot and I) ran the "MAIN CARGO FIRE" checklist while FO handled

communications with ATC. "MAIN CARGO LIGHT" extinguished before we depressurize

aircraft so checklist was stopped. We as a crew discussed and agreed we had no visual

indication of smoke or fire to dump fuel and return without [advising ATC of an]

emergency. We advised ATC we would need to dump fuel and it would be 24 mins to

dump 117k pounds. On completing dumping of fuel we had a fuel imbalance of 3000. We

asked ATC for more vectors to run checklist. When all checklist complete, FO flew a

coupled approach ILS 15 to a full stop.

Narrative: 2


Synopsis

B747-400 flight crew reported experiencing a "MAIN CABIN SMOKE" light shortly after

takeoff. Crew elected to return to departure airport.

ACN: 1451548 (46 of 50)

Time / Day

Date : 201705


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : Bonanza 35



Flight Plan : IFR

Mission : Personal





Component



Problem : Failed

Person

Reference : 1











Events



Anomaly.Inflight Event / Encounter : Loss Of Aircraft Control





Assessments



Narrative: 1

A BE35 Bonanza departed ZZZ at approximately XA:30 for a direct flight to ZZZ1. At

approximately XC:15 I diverted to ZZZ2 upon observation of a continual spray out of the

cap of the right main fuel tank. I landed and had minor greasing of cap and subsequently

departed to ZZZ1 (destination). At approximately XD:40 a sudden and violent turn and

descent occurred. I immediately controlled the yoke to reestablish level flight, searched for

handle to move gas flow from right to left main and [advised] ATC. As control and checks

were executed I decided to divert to ZZZ3. With the plane maintaining altitude and power

I executed a non-eventful landing at ZZZ3 after 2 attempts. Once on the ground there was

a leak of gas from under the engine.

My major advice is to be aware that a situation can develop in a number of seconds and

keep a record of all fuel used and time remaining.

Synopsis

BE-35 pilot reported diverting due to a loss of fuel out of the right fuel cap, then diverting

again later after losing power associated with a fuel leak.

ACN: 1451200 (47 of 50)

Time / Day

Date : 201705


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : Light Sport Aircraft



Flight Plan : VFR

Mission : Personal




Person

Reference : 1





Qualification.Flight Crew : Sport / Recreational








Events







Assessments

Contributing Factors / Situations : Chart Or Publication



Narrative: 1

I received a standard weather briefing. Good weather and favorable winds all the way.

Plotted the course using Foreflight with its moving map display, on an iPad. Program

calculated fuel usage from numbers put into the program. Considering weather and fuel

burn rate and quantity, I should have had enough fuel for the first leg with at least 30

minutes of fuel remaining. There were a few spots where I flew into head winds, but other

times I flew at indicated speed of 95 or more. I kept an eye on the fuel sight tubes and the

right tank tends to draw faster. As I approached [destination] it became apparent that I

wouldn't have that full 30 minutes worth left over. I closed my flight plan and flight

following. When the right tank was empty it started drawing from the left tank fairly

quickly.

I contacted the Tower and got clearance to enter a left downwind for landing. About 1 mile

from the airport, I was over housing, the engine started to cough and then quit. I knew

immediately that I had run out of fuel. I stabilized the aircraft, found a field that I thought

I could make it to, contacted the tower and told them I was out of fuel. They said I could

land on any runway, but I was quickly losing altitude and airspeed. I was over houses at

the time, there was a small green field off the right, and power lines right along the edge

of the field. I just cleared the power lines, then had to bank sharply right and lose the last

50-75 feet of altitude immediately. Tower was still offering immediate landing, but I would

have to cross a freeway. The field was my only hope. Had full flaps deployed. Got on the

ground and found it to be very rough. Was able to stop safely about 10 ft from a ditch,

with a fence and the freeway on the other side. Contacted the tower to let them know I

was okay and plane was not damaged. They called 911 and a sheriff responded within 10

minutes. He asked how I was doing and if plane was damaged. Then he left to find a way

into the field.

While he was gone I contacted the plane manufacturer to find the best way to tow it. They

strongly recommended not towing it because it would probably damage the landing gear.

They recommended flying off the field. The tower recommended against this, but there

was no way to get it out of the field. Tower made sure I realized I would be fully

responsible for the flight. The sheriff and tow truck drivers arrived and told me how rough

the field was and that there were a few deep ruts that ran across the field. I put a

minimum amount of fuel in to reduce weight. The wind had shifted, and I had to taxi

carefully to the other end of the field. I had walked it and knew the takeoff route that I

should follow.

With full flaps I gave it full throttle, released the brakes, and began my roll. The grass was

fairly tall, and there were big hummocks that made for a very rough ride and slow

acceleration. Finally the plane lifted off just before I reached the ditch and I got over the

fence. Leveled out about 10 ft. above the freeway to pick up speed, and then climbed out

normally. Had the tower put glasses on the landing gear to make sure nothing was

damaged on the rough takeoff roll. Made a normal landing then with emergency vehicles

following. Refueled at that point and after hearing from both the tower and the sheriff,

who had talked with FAA, I continued my flight, with one more stop for fuel.

Rechecked calculations for fuel burn that evening and found that the numbers I was using,

which I had gotten from a website, were wrong. When I found more accurate numbers and

recalculated. I found that I didn't really have enough gas to complete this first leg safely. I

have since then changed those numbers and recalculated my fuel usage for the trip home.

With one additional fuel stop, I can make it to each refueling stop with plenty of fuel left

over at each stop.

Synopsis

LSA pilot reported an off-airport landing after a fuel miscalculation led to the tanks running

dry.

ACN: 1450668 (48 of 50)

Time / Day

Date : 201705


Place





Environment



Light : Daylight


RVR.Single Value : 2

Aircraft

Reference : X



Make Model Name : Cessna 150



Flight Plan : VFR

Mission : Personal



Airspace.Class C : ZZZ

Component : 1




Component : 2




Component : 3



Person

Reference : 1












Events








Assessments



Narrative: 1

On short final after a 3.4 hour cross-country flight the engine quit. [ATC was advised] and

pilot safely operated an engine failure landing on runway, vacating the runway as well.

Engine failure was due to faulty fuel gauge indicating aircraft had adequate fuel present

when fuel starvation occurred.

Synopsis

C150 pilot reported a loss of engine power on short final due to fuel exhaustion that

resulted in a dead-stick landing.

ACN: 1450636 (49 of 50)

Time / Day

Date : 201705


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : Cessna 310/T310C



Flight Plan : IFR

Mission : Personal

Nav In Use : GPS



Component

Aircraft Component : Electrical Power


Problem : Failed

Person

Reference : 1

















Events








Assessments



Narrative: 1

In flight, total electrical failure in VMC on IFR flight plan. First indication was Center saying

they couldn't see my transponder, anymore. When my headset started doing static and

GPS flickered, I advised Center I might have pending total electrical failure. It failed

shortly thereafter. Going to standby voltage regulator got my radio back, but not the

screen, and the radio came up in Guard and an airline flight was trying to relay for me

before I lost that a minute later, too. I then lost all cockpit avionics including GPS, moving

map, radios, etc. All gages froze in last position and I was forced to hand crank the landing

gear down and land no-flap (non-standard) at the nearest field as I was just about to

switch from near empty aux tanks to the mains and was not certain if an electrical relay

was needed, so I wondered if I was about to lose the engines, too, with no suitable field to

do a forced landing. The gear held upon landing.

A mechanic is investigating the voltage regulators and alternators. The batteries were

brand new. The ammeter in the older C-310 does not give really accurate info other than

flow trends. A voltmeter would be preferred. More frequent inflight checks of electrical

system advised, especially IFR. It turns out the fuel valves are mechanical, so I had more

fuel (and could have had less stress), but airmanship still dictated landing at the nearest

field with total electrical loss.

Bottom line, I'm glad I did not overfly a good piece of concrete to find a better one. A

handheld transceiver would have been nice, but I might not have had time to use it

potentially violating the aviate-navigate-communicate priorities. Backup navigation like

iPad very helpful in situations like this.

Synopsis

C310 pilot reported a complete electrical system failure in visual conditions that resulted in

a diversion to a nearby airport.

ACN: 1450417 (50 of 50)

Time / Day

Date : 201704


Place




Environment

Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : MCP


Problem : Failed

Person

Reference : 1







Events







Assessments




Narrative: 1

Flight departed from IND at XA:59, at approximately XB:05, I received a call from the

Departure station personnel saying that the flight was requesting to talk to me on ZZZ

operations frequency. I pulled up the station radio and while doing that I zoomed in on the

ZZZ area on my map and the flight had leveled off at 10,000 feet and appeared to be

circling the area. I made contact with the flight and the captain stated right after

departure they had a Mode Control Panel failure. They had lost the autopilot and were

flying visually on vectors only. I advised the captain to return to ZZZ and provided the

time and my initials to show an air return.

After I got off the radio, I sent a request to the aircraft to obtain fuel and weight

information from FMC which indicated that fuel on board was 8,500 lbs. I thought that was

low but did not investigate further due to my rush to calculate numbers. I received the

report back and ran the numbers. I showed a burn from his present position back to ZZZ

as 600 lbs with a landing weight of 122,800 lbs. A couple of minutes later, I realized I sent

the request to the wrong aircraft which had been a different model of the 737 also flying

from ZZZ. After realizing this error, I re-ran the numbers with the correct information and

put a corrected amendment on the release. The fuel burn remained the same at 600 lbs,

with 16,600 lbs fuel on board, and estimated landing weight of 118,600 lbs. The reason

for this error is because I felt rushed to calculate proper numbers prior to the aircraft

landing. Since it was so close to the airport, I felt like I didn't have much time and had to

accomplish the task prior to the aircraft landing even though I had told the captain to

show an air return at XB:10 with my initials. After landing, captain called me and said that

the MCP failure had occurred at approximately 100 feet AGL, right after they had retracted

the gear. He stated in his rush to prepare for landing, he and the FO forgot to declare an

emergency with ATC. He also stated that ATC never asked about emergency declaration

either.

I need to slow down and not try to rush when accomplishing my work. I should verify the

information I am using is correct. Even though in this case, an air return was appropriate,

it might have been possible to continue to the planned destination. Next time, I could ask

the captain how he felt about continuing.

Synopsis

B737 Dispatcher reported a flight had a MCP failure after takeoff and advised the Captain

to return to the departure airport.

Fuel Management Issues - ASRS - Aviation Safety … · · 2017-11-23Fuel Management Issues . ......

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