Fuel Management Issues - Aviation Safety Reporting System - NASA

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 ....................................................31.0

Date of Update .....................................................May 31, 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: 1430291 (1 of 50)

Synopsis A330 Flight Attendant reported an odd odor in the cabin that resulted in physical

symptoms related to the odor.

ACN: 1430235 (2 of 50)

Synopsis Air carrier Captain reported several go-arounds due to windshear warnings at DTW, then

finally landed during a windshear caution alert on the third approach.

ACN: 1429918 (3 of 50)

Synopsis Air carrier First Officer reported three windshear go-arounds during approaches to DEN

Runway 16L. After declaring a low fuel alert, a successful landing was accomplished on

Runway 26.

ACN: 1429606 (4 of 50)

Synopsis Air Carrier Captain reported multiple go-arounds due to wind shear alerts from ATC at

DEN, he finally decided to land on runway 26 with a crosswind very close to limits.

ACN: 1429605 (5 of 50)

Synopsis Air Carrier Captain reported that extreme winds at LAS created unsafe landing conditions.

The flight diverted to a nearby airport with more safe conditions and landed normally.

ACN: 1429176 (6 of 50)

Synopsis A320 First Officer reported a windshear alert just prior to touchdown. They elected to land

rather than execute the windshear recovery as required by SOP.

ACN: 1428893 (7 of 50)

Synopsis ERJ-170 Dispatcher and First Officer reported that due to strong headwinds flight planned

to divert; however, winds decreased and Crew proceeded to destination but landed with

less than reserve fuel.

ACN: 1428526 (8 of 50)

Synopsis EMB175 Captain reported diverting to the alternate airport after two missed approaches at

the planned destination.

ACN: 1427206 (9 of 50)

Synopsis Air carrier flight crew reported they experienced a windshear alert on final to RJAA,

executed a go-around, and diverted.

ACN: 1427048 (10 of 50)

Synopsis B737 flight crew reported a fuel leak was discovered in flight and the crew elected to

divert. Maintenance determined an aircraft fuel quantity indication anomaly was the cause.

ACN: 1426762 (11 of 50)

Synopsis A Flight Instructor reported his instrument student moved the fuel tank selector to the OFF

position while attempting to change engine fuel sources. The Instructor determined the

engine failure cause and restarted the engine.

ACN: 1426386 (12 of 50)

Synopsis A CRJ-900 First Officer reported a fuel burn of approximately 2,000 pounds over planned

because climb temperatures were between ISA+15 and ISA+25 coupled with ATC delays.

ACN: 1426149 (13 of 50)

Synopsis B737 flight crew reported diverting to a nearby alternate when the weather at destination

started to cause missed approaches. The forecast at departure did not require an

alternate.

ACN: 1425891 (14 of 50)

Synopsis Piper PA-28 flight instructor reported an aborted takeoff due to loss of power.

ACN: 1425841 (15 of 50)

Synopsis Two pilots in a PA28 reported they experienced a power loss when they ran a tank dry

while engaged in conversation.

ACN: 1425423 (16 of 50)

Synopsis Air Carrier Captain reported a problem with the fuel tank distribution system resulting in

near out of balance limits. Flight landed without incident.

ACN: 1425364 (17 of 50)

Synopsis PA-31 Captain reported an issue with the right engine fuel pressure during cruise. Captain

secured the engine and returned to the departure airport.

ACN: 1425275 (18 of 50)

Synopsis A319 Captain reported a GPWS warning for flap setting following a side step maneuver to

a longer runway.

ACN: 1424199 (19 of 50)

Synopsis Air carrier Dispatcher and First Officer reported an issue with the company dispatch

computer system which does not reflect accurate fuel burns on specific international flights

and sometimes jeopardizes legal re-dispatch points.

ACN: 1423944 (20 of 50)

Synopsis A pilot of a Cessna 150 reported that he ran out of gas prior to reaching the airport.

ACN: 1423725 (21 of 50)

Synopsis Air Carrier Captain reported a missed approach due to weather which ultimately resulted in

a diversion due to low fuel.

ACN: 1423633 (22 of 50)

Synopsis Air carrier flight crew reported flying a missed approach while attempting the SAN RNAV Y

Runway 27 due to weather.

ACN: 1422923 (23 of 50)

Synopsis

Oakland Center Controller reported unsafe airspace problems with a Navy Facility when

military flights enter Oakland Airspace without approval.

ACN: 1422415 (24 of 50)

Synopsis Boeing 737 flight crew reported their electric elevator trim system failed after takeoff.

They ran the checklist and returned to land at departure airport using the manual trim

instead.

ACN: 1422220 (25 of 50)

Synopsis An Ercoupe 415 pilot reported that the fuel indicator for the header tank indicated he was

losing fuel.

ACN: 1421585 (26 of 50)

Synopsis A B767-300 pilot reported that center tank fuel was used primarily by the right engine

leaving the amount of fuel in the wing tanks unbalanced.

ACN: 1421162 (27 of 50)

Synopsis A300 flight crew reported an unexplained decrease in right outer fuel quantity and

diverted.

ACN: 1420814 (28 of 50)

Synopsis B737 First Officer reported diverting to an alternate after experiencing windshear on two

consecutive approaches to BWI.

ACN: 1420276 (29 of 50)

Synopsis MD-80 Captain reported what he feels is a flaw in a company MEL procedure dealing with

Forward Aux Transfer Pumps Inoperative.

ACN: 1420269 (30 of 50)

Synopsis CRJ-700 flight crew reported shutting down the engine inflight and evacuating on the

runway after receiving an engine fire warning during the approach.

ACN: 1419897 (31 of 50)

Synopsis A319 First Officer reported receiving a low altitude alert from ATC on a night visual

approach to DCA.

ACN: 1419576 (32 of 50)

Synopsis C172 instructor pilot reported experiencing engine failure on the takeoff roll that was later

traced to water in the fuel.

ACN: 1419551 (33 of 50)

Synopsis Flight Attendants reported diverting due to fuel issues. The flight had difficulty getting a

gate and after a long period of time the Captain ordered a single slide to be deployed. Air

stairs were used to deplane the passengers.

ACN: 1419034 (34 of 50)

Synopsis B737NG flight crew reported disconnecting the autothrottles and aircraft slowing to

BUFFET ALERT message airspeed after missed approach.

ACN: 1418563 (35 of 50)

Synopsis Air Carrier Captain was put into holding unexpectedly and determined the aircraft didn't

have sufficient reserve fuel for the Expect Further Clearance time given. No alternate

airport was included on the flight plan so Dispatch amended the flight plan and they

diverted to an alternate.

ACN: 1417403 (36 of 50)

Synopsis Passenger turbojet flight reported of an unexpected holding for the destination resulting in

landing with minimum fuel.

ACN: 1417212 (37 of 50)

Synopsis B777 Captain reported of a fuel imbalance which was caused by a possible fuel leak or

malfunctioning fuel gauge. ATC was advised and a normal landing ensues.

ACN: 1416985 (38 of 50)

Synopsis Boeing 777 Captain reported a discrepancy in the FMC fuel remaining estimate. Initially it

showed they would be landing with extra fuel, then 5 hours into the flight it showed they

would be landing with less fuel than planned. It may have been due to an un-forecasted

wind shift.

ACN: 1416597 (39 of 50)

Synopsis CRJ-900 Captain declared minimum fuel after unexpected holding on descent to their

destination. The Captain attributed fuel issues to unrealistic company fuel reserve policies.

ACN: 1415563 (40 of 50)

Synopsis BE58 pilot reported that no NOTAMs had been issued for several airports that were closed

due to runway conditions. ATC was also unaware of the closures.

ACN: 1415378 (41 of 50)

Synopsis B757 Captain reported a fuel quantity gauge and fuel pump anomalies during climb out

and elected to divert to a suitable alternate for maintenance.

ACN: 1415219 (42 of 50)

Synopsis A330 flight crew reported experiencing a fuel quantity anomaly on a trans-Atlantic flight

that indicated a possible fuel leak. The flight was able to safely continue to destination.

ACN: 1414688 (43 of 50)

Synopsis CRJ-700 Captain reported striking the runway with a wingtip on landing flare in shifting

wind conditions.

ACN: 1414140 (44 of 50)

Synopsis CE-680 flight crew reported diverting to an alternate after receiving Crew Alerting System

(CAS) message FUEL FLTR BYPASS R, an indication of possible fuel contamination.

ACN: 1413982 (45 of 50)

Synopsis

B737 flight crew reported a significant fuel tank imbalance after takeoff and right roll

tendency. They returned to base where fuel imbalance was confirmed. An improper fuel

audit and initially inaccurate fuel gauge were cited as causes.

ACN: 1413897 (46 of 50)

Synopsis Kitfox 7 pilot reported a loss of power due to possible fuel system problems and no ram air

due to rotated pitot tube while on downwind. The pilot attempted to land well short of the

runway in the grass, and the nose gear collapsed on landing.

ACN: 1413892 (47 of 50)

Synopsis Hawker 800XP flight crew reported diverting to an alternate because of an increasing fuel

imbalance related to a FUEL 1 LOW PRESSURE warning.

ACN: 1413603 (48 of 50)

Synopsis Air taxi pilot reported departing with insufficient fuel to reach its destination and shortly

after takeoff returned to the departure airport.

ACN: 1412795 (49 of 50)

Synopsis Air carrier flight crew reported a diversion to BTV after runway conditions deteriorated at

CYUL. Captain reported BTV was not a very good alternate, but due to their fuel state

elected to successfully land even though he received a windshear alert on the second

approach.

ACN: 1412791 (50 of 50)

Synopsis EMB-145LR Captain reported landing with unusually low fuel quantity even though his

enroute fuel checks were all normal, and there were no arrival delays.

Report Narratives

ACN: 1430291 (1 of 50)

Time / Day

Date : 201611

Place

Locale Reference.Airport : ZZZ.Airport

State Reference : US

Aircraft

Reference : X

Aircraft Operator : Air Carrier

Make Model Name : A330

Crew Size.Number Of Crew : 2

Operating Under FAR Part : Part 121

Mission : Passenger

Flight Phase : Climb

Maintenance Status.Maintenance Type : Unscheduled Maintenance

Maintenance Status.Maintenance Items Involved : Repair

Component

Aircraft Component : Fuel System

Aircraft Reference : X

Problem : Malfunctioning

Person

Reference : 1

Location Of Person : Company

Location In Aircraft : General Seating Area

Reporter Organization : Air Carrier

Function.Flight Attendant : Flight Attendant (On Duty)

Qualification.Flight Attendant : Current

ASRS Report Number.Accession Number : 1430291

Human Factors : Physiological - Other

Events

Anomaly.Aircraft Equipment Problem : Less Severe

Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor

Anomaly.Flight Deck / Cabin / Aircraft Event : Illness

Anomaly.Deviation - Procedural : Published Material / Policy

Detector.Person : Flight Attendant

Were Passengers Involved In Event : Y

When Detected : In-flight

Result.General : Physical Injury / Incapacitation

Assessments

Contributing Factors / Situations : Aircraft

Primary Problem : Aircraft

Narrative: 1

Before we even left, we had a fuel leak. It was eventually fixed and we departed for ZZZ.

On the climb I smelled an odor, but I figured it was from the repair and it wasn't too bad.

We were all strapped into our jump seats (I was at the 3L) on the descent into ZZZ when

a very strong odor was detected. It smelled like a combination of deicing fluid and dirty

locker room odor. It was so strong I had to breathe into my sleeve and I looked over at

the other Flight Attendant sitting at the 3R jumpseat and she was doing the same thing.

My eyes began to sting as well as my throat. Several passengers asked me what the smell

was and I literally couldn't answer them because I began to cough.

The passenger right in front of me put her sweater over her nose and mouth. All

passengers deplaned and the crew gathered at the front as we discussed what had just

occurred. Flight Services were called and [someone] met us to take us to the Airport

Urgent Care Facility for employees. We filled out paperwork and I was brought to the back

where they weighed me, took my height measurements, looked into my eyes, throat,

ears, and nose, and took my blood pressure. I told her my eyes were still stinging and my

throat burned, along with a headache. She gave me Advil, Benadryl for my throat, and 5

vials of eye drops. I ask her if she was going to draw my blood and she was puzzled by it.

I then went back out to the waiting room [and was] informed if we wanted our blood

tested, we would have to go to the hospital. I declined because it had already been

[several] hours of all of this and I felt like it had been a waste of time. No one seemed to

know what the protocol was to deal with this event.

Synopsis

A330 Flight Attendant reported an odd odor in the cabin that resulted in physical

symptoms related to the odor.

ACN: 1430235 (2 of 50)

Time / Day

Date : 201703

Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : DTW.Airport

State Reference : MI

Altitude.AGL.Single Value : 1000

Environment

Flight Conditions : VMC

Weather Elements / Visibility : Turbulence

Weather Elements / Visibility : Windshear

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : DTW


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



Flight Plan : IFR

Mission : Passenger

Flight Phase : Final Approach

Route In Use : Visual Approach

Airspace.Class B : DTW

Person

Reference : 1

Location Of Person.Aircraft : X

Location In Aircraft : Flight Deck


Function.Flight Crew : Captain

Function.Flight Crew : Pilot Flying

Qualification.Flight Crew : Air Transport Pilot (ATP)


Events

Anomaly.Deviation - Speed : All Types


Anomaly.Inflight Event / Encounter : Weather / Turbulence

Anomaly.Inflight Event / Encounter : Unstabilized Approach

Anomaly.Inflight Event / Encounter : Fuel Issue

Detector.Person : Flight Crew


Result.Flight Crew : Executed Go Around / Missed Approach

Assessments

Contributing Factors / Situations : Weather

Primary Problem : Weather

Narrative: 1

Arriving, the winds in DTW were reporting approximately 220@23G29. During the descent,

we started to encounter moderate turbulence around 4,000 ft MSL and it continued

throughout the entire approach each time. We were cleared for the visual approach to 22R

and upon contacting tower, we were advised the wind again (same as we had on the ATIS)

while being cleared to land. At approximately 1,000 ft, after flying through continuous

moderate turbulence (with the expected airspeed fluctuations), we received a windshear

warning and immediately executed the windshear escape maneuver. After we cleared the

windshear warning (maybe 5 seconds later), we were vectored around for another

approach. At this point, we had approximately 2100 lbs of fuel on board when we briefed

the approach (for the second time) and since we did not have any alternates and the

winds were just as bad when we took off, I decided to continue for a second approach.

The second approach mirrored the first approach with the winds being approximately

240@27G37 now. After being cleared for the visual approach, when we were handed off to

tower after getting configured to flaps 45, we heard another airplane go around due to

windshear. We continued in and this time at approximately 800 ft AGL, we received

another windshear warning and immediately executed the windshear escape maneuver.

After leveling off after this go around we were at approximately 1670 lbs of fuel remaining.

At this point, we declared minimum fuel and requested another approach to 22R in DTW

after determining that all of DTW's runways were experiencing the same windshear

events.

On the third approach, I briefed that I would be continuing to land and that I would be

aiming for an airspeed somewhere in the middle between the bugged airspeed (Vref + 10

knots) and the Vfe flaps 45 (170 kt) to ensure minimal altitude loss, if we did receive a

third windshear event. During the final approach with flaps 45, we experienced the same

moderate turbulence throughout the approach however, instead of a windshear warning,

we received a windshear caution due to a 20-30 knot airspeed gain at approximately 500

ft AGL. At this point I went to idle thrust but our airspeed continued above 170 kts. The

clacker sounded for approximately 5-7 seconds before finally slowing back to my target

speed. After this event, we were able to continue to a landing with no windshear warning

events. We arrived on the ground with approximately 1100 lbs of fuel remaining on board.

I wrote up both windshear escape maneuvers and the flap overspeed event in the

maintenance log when we arrived at the gate.

Prior to [departure], I [had] reviewed the wind report and forecast for DTW and it was

reported at 220@23G29 at XA:53 and forecast to be 230@22G34 From XD:00 until XF:00

(Scheduled Arrival = XD:45) so I did not think much of the winds prior to departing. When

we pushed back from the gate, we had approximately 2800 lbs of fuel predicted to be on

board after landing in DTW but because the winds were not forecast to be anywhere near

as significant as they were, I did not consider adding an alternate airport with calmer

winds before we departed. With regards to the last approach with the flap over-speed,

since I intended to prevent altitude/airspeed decay if we did encounter another windshear

event, I believe my target airspeed was appropriate for the conditions, given what we had

experienced on the first two approaches. Since we did not encounter any positive

performance windshear events (that were notable beyond the continuous moderate

turbulence), I simply did not expect to encounter it. Although I responded immediately

with idle thrust and a slight pitch up, I could not stop it from exceeding the flap speed

without becoming too out of position to continue the approach, which was my primary

concern at this point due to our fuel status.

At this time, I am genuinely at a loss for what preflight planning step I could have taken to

avoid being put in this situation. Because of the winds in ZZZ, I knew it was going to be

turbulent but, with the winds approximately "right down the runway" at DTW and a 12

knot difference between the worst sustained wind and gust factor on the METAR/TAF

(much "better" than the winds we just arrived in ZZZ with), I simply did not judge this

threat to be as concerning as it would become. The only thing I can think of that would

have at least given me a slightly bigger weather picture would have been to look at a

station model plot chart or ask my dispatcher which direction we needed to fly to get to an

airport with calmer surface winds however, as I said above, my judgement of how

threatening the winds in DTW were before takeoff would still probably not lead me to

consider this option, if I was to repeat this scenario.

After the first windshear go around, I considered a possible divert with 2100 lbs of fuel

but, based on how bad it was in ZZZ (over 100 miles away and just as turbulent/windy), I

did not think we could make it anywhere where the winds would be better and even if we

could, DTW had a 10,000 ft runway with winds, more or less, straight down the runway so

I decided our safest course was to attempt the approach again in DTW.

Synopsis

Air carrier Captain reported several go-arounds due to windshear warnings at DTW, then

finally landed during a windshear caution alert on the third approach.

ACN: 1429918 (3 of 50)

Time / Day

Date : 201703


Place

Locale Reference.Airport : DEN.Airport

State Reference : CO


Environment



Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : DEN


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



Flight Plan : IFR

Mission : Passenger

Nav In Use : FMS Or FMC

Nav In Use : GPS

Flight Phase : Landing


Airspace.Class B : DEN

Person

Reference : 1




Function.Flight Crew : First Officer

Function.Flight Crew : Pilot Not Flying


Experience.Flight Crew.Total : 1905

Experience.Flight Crew.Type : 304


Human Factors : Time Pressure

Human Factors : Workload

Events




Detector.Person : Air Traffic Control


Result.Flight Crew : Took Evasive Action

Result.Flight Crew : Landed As Precaution

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


Result.Air Traffic Control : Issued Advisory / Alert

Assessments




Narrative: 1

During climb out, I picked up ATIS for Denver. The winds were strong (as we had

anticipated from the forecast) and we discussed the current winds, gusts, LLWS advisory,

and the microburst advisory. Since the ATIS included windshear and microburst alerts, the

Captain sent texts to Dispatch to inquire about Thunderstorm activity, as well as to

express concern about the microburst. Dispatch replied that there were no thunderstorms

and while the winds were gusty, there was only a crosswind component of 13 for the

16L/R runways. Dispatch later informed that the winds were picking up, but other

operators were getting in. Windshear recognition, avoidance and recovery procedures

were reviewed in the AOM.

Enroute we discussed the option to going to COS, however, the ATIS was just as poor for

[the alternate] as it was for DEN. We received two more ATIS updates for DEN enroute,

and the reports were not improving. Our second to last report was received around XA10

and indicated the winds to be 20027G35 during arrival. The final ATIS report was

19028G39KT.

We had set-up and briefed for 16L. On the arrival, ATC informed us to expect the approach

to 16L. When we were on downwind leg, another operator in front of us was cleared to

land 16L, and was able to get in. We were then cleared for the visual approach for 16L.

During our first attempt to shoot the approach, we had approximately 4100lbs of fuel.

When on final, a tower-issued windshear alert was announced for 16L, and a go-around

was initiated. The go-around procedure was uneventful, and all the proper call-outs were

made. Positive transfer of the flight controls were made to allow the Captain to message

Dispatch.

We requested another attempt for the same runway. During our second approach check,

there was approximately 3600lbs of fuel. We were vectored for the approach, and when on

final just inside of the FAF, another Windshear alert was issued, accompanied with a

Microburst advisory. A second go-around was initiated.

At some time after leveling off, following the go-around, I attempted to retrieve an ATIS

for [a second alternate], but did not receive any info back. We discussed [the second

alternate] briefly, but the distance was going be an issue. At some point, tower informed

us [of another airport], where the wind was straight down the runway, gusting to 32. We

discussed landing 26 at DEN as an option. We continued to plan for another attempt at

16L. During our third attempt, there was approximately 3100lbs of fuel at the completion

of the approach check.

During the third attempt, yet another windshear alert was issued, and another go around

was initiated. The option to land on 26 was discussed further. Tower said that other

operators have been using this runway, and no alerts had been issued. We requested 26,

and were sequenced as #2, to follow other inbound traffic.

During the approach check to runway 26, there was approximately 2800lbs of fuel. The

initial wind report was outside of the aircraft limitations, and we were running low of fuel.

When we were on final, I noted that fuel was at 2600lbs and the last reported wind from

tower was 190/30. A low fuel state was declared while on final, and we landed without

incident. During the spoiler callout, I had noticed the fuel indication changed from normal

illumination to amber.

Synopsis

Air carrier First Officer reported three windshear go-arounds during approaches to DEN

Runway 16L. After declaring a low fuel alert, a successful landing was accomplished on

Runway 26.

ACN: 1429606 (4 of 50)

Time / Day

Date : 201703


Place

Locale Reference.Airport : DEN.Airport

State Reference : CO


Environment


Aircraft

Reference : X

ATC / Advisory.Tower : DEN

ATC / Advisory.TRACON : D01


Make Model Name : Medium Large Transport



Flight Plan : IFR

Mission : Passenger



Airspace.Class B : DEN

Person

Reference : 1








Human Factors : Communication Breakdown



Communication Breakdown.Party1 : Flight Crew

Communication Breakdown.Party2 : Dispatch

Events








Assessments

Contributing Factors / Situations : Company Policy

Contributing Factors / Situations : Human Factors



Narrative: 1

During our flight into Denver we experienced issues with high winds that made for very

difficult circumstances landing at the airport. Prior to our descent into Denver we pulled an

ATIS for Denver. The ATIS was reporting microburst advisories and wind shear advisories

in effect. I had seen these in the past due to winds and convective activity so I was

concerned that the situation in Denver was worsening. I sent a message to dispatch to see

if there was weather building in the area. The dispatcher replied that there was not. The

dispatcher then sent a message a few minutes later "YA GUSTY WINDS...CROSSWIND

COMPONENT IS 13 KNOTS FOR THE 16S GAVE EXTRA CONT FOR WINDS". The dispatcher

also said that they would keep an eye on Denver and let us know if anything changed. I

was still concerned that we could potentially encounter wind shear on our approach into

Denver, but felt better that the dispatcher was checking on the status of the airport.

Upon texting with dispatch prior to our descent they told us that everyone was getting in

and landing on the 16s, and that the cross wind would be 13 knots. Upon approach to

Denver we were told that microburst advisories were in effect with possible loss of 25

knots. We ran our approach checklists and were vectored on to runway 16L for a visual

approach, backed up with the ILS. There was another airplane on approach to that

runway, they landed and did not report any wind shear. As we were descending on the

approach and at about 1500 feet tower issued a wind shear alert. We initiated a go around

and started climbing out. We were then vectored around for another approach. While

being vectored I texted dispatch and told them that I need to know other options. While

we waited to hear from dispatch we were vectored in for another approach. Several

minutes went by before we heard back from dispatch. The message from them was "Looks

like you're on final, and everyone else is landing." That is not quoted verbatim what the

message said, as I don't remember exactly. I do know that I asked for options and what I

got back was a message that had no additional information--no alternative options to

landing in Denver. This time we were given the visual approach to 16L, there were no wind

shear alerts or microburst alerts for the runway when initiating the approach. Another

aircraft had actually just landed and did not advise of any wind shear. We commenced the

approach.

Again at approximately 1500 feet we received another wind shear alert from tower. We

initiated the go around and started climbing out. Again we were vectored for another

approach to runway 16L. It should be noted that while we were doing approaches to

runway 16L, all the other runways were getting alerts as well. I asked about 16R, and

17R, both had the same wind shear alerts. Tower let us know that 16L alerts were the

least frequent. As we were proceeding inbound on approach for 16L they issued a

microburst alert and a wind shear alert. We again commenced a go around, and again

asked ATC about other options. Runway 26 which had previously been outside of our

crosswind limitations was still outside of our limitations but steady around 33 knots.

[Another aircraft] who was behind us on the last of our approaches to 16L also asked for

runway 26. We set up for the approach and were vectored for the visual.

At this point during the flight our fuel was around 2750. [Alternate] was no longer a viable

option due to fuel requirements and the unknowns about what exactly the weather was

doing there.

As we were being vectored to the visual our fuel was becoming a more severe issue. I

decided to [advise] ATC for low fuel and crosswinds out of limits for the airplane. They

gave us the option of going to ZZZ. I was unfamiliar with that airport and whether or not it

had acceptable safety systems in place for wind shear and microburst alerting, so decided

to consider a landing there, but we still had the fuel to continue to Denver's runway 26.

When we were given clearance to land the winds tower reported were 190 at 30 knots. I

knew this was very close to our limitation, possibly just outside of it, but I was much more

comfortable with a steady 30 knot crosswind than gusty winds and possible wind shear. I

am familiar with how the limitation is worded in our Aircraft Operations Manual (AOM),

specifically, it says that it is demonstrated and not considered limiting. After [the other

aircraft] landed tower advised they had a "smooth ride down to 26." At 1000 feet we were

configured and on speed and the airplane was performing very well. There was a

substantial crab angle, as we did have 30 knots of crosswind, but I believe the winds

decreased slightly when we landed, as the landing was a pretty normal crosswind landing.

This leads me to believe that the landing may have actually occurred within our limitation.

After we landed we taxied clear of the runway, and to the gate.

There are some points that I think are important to make, and some decisions that I think

could have been different, though the circumstances were very difficult and I'm not sure

what could have been differently.

Leaving [departure airport] we were given 753 pounds of contingency fuel. This put our

planned landing fuel into Denver at 3703 pounds. The weather forecast for Denver was

showing winds to be 240 at 24 gusting to 34. Having flown into Denver numerous times, I

am familiar with the airport and the weather times often associated with it. The wind

forecast seemed to me to be pretty common for the airport. It was well within limitations

for landing on runway 16L, and would also be a non-issue for landing on runway 26.

Because, of the potential wind shear into Denver, the First Officer (FO) and I discussed

and briefed the wind shear recovery technique as described in the AOM. We also agreed

not to attempt an approach if there was a wind shear alert active. I referenced the AOM,

as well as the Summer Operations guide, and the Hazardous Weather Decision Aid so that

information would be fresh in my mind in the case we encountered any wind shear on

approach.

The Hazardous Weather Decision Aid, I found to be quite helpful, though some of the

information a little vague. It specifically mentioned microburst advisories and alerts and

assessed the risk associated with proceeding to an airport with such advisories. I found

the risk during our arrival to be medium, as these advisories were in effect. High risk

would have included any PIREP of a wind shift greater than 15 knots as well as many other

bullet points, the rest of which didn't apply, but still decided to proceed under the high risk

guidance. However, at no point did I receive a pilot report from previously landing pilots

that they had any loss of airspeed. I also briefed that the flight crew actions for Runway

specific wind shear or microburst alert would be that no takeoffs or landings could be

attempted to that specific runway.

I would like to know more about what can be done in this type of situation, and what can

be done to avoid it. If a pilot finds himself in the situation again, what would the company

consider the safest course of action? I would like to see more guidance on how to deal

with wind shear, what we can and cannot do, and specific time limits before attempting

approaches. The hazardous weather decision guide has a note that wind shear and

Microburst Alerts are for 1 minute after ATC report then becomes an advisory. I would like

to know more about this specifically.

It may be a good idea to issue alternate airports for instances when the destination is

going to have wind shear or microburst advisories in effect.

We need better communication between pilot and dispatch. I don't recall exactly what was

in the messages I sent to dispatch, but at one point I did ask for other options. My

assumption would be that dispatch would check weather, call the alternate tower and ask

if they were having wind shear issues then send me weather and NOTAMs for that

alternate with a message that reads something like "Go to alternate". Unfortunately the

response I received was something like "everybody else is landing." My frustration is that I

asked for help and didn't get any. I didn't have time for discussion, I just needed an out

right then and there.

Also, clarification on our crosswind "limitation" would be helpful. Perhaps a safer course of

action on arrival into Denver would have been an approach to runway 26 with the slightly

stronger crosswind than our "limit."

Synopsis

Air Carrier Captain reported multiple go-arounds due to wind shear alerts from ATC at

DEN, he finally decided to land on runway 26 with a crosswind very close to limits.

ACN: 1429605 (5 of 50)

Time / Day

Date : 201703


Place

Locale Reference.Airport : LAS.Airport

State Reference : NV


Environment




Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : LAS





Flight Plan : IFR

Mission : Passenger




Route In Use.STAR : KEPEC4

Airspace.Class B : LAS

Person

Reference : 1









Events








Result.Flight Crew : FLC Overrode Automation

Result.Flight Crew : Diverted

Result.Air Traffic Control : Provided Assistance

Assessments

Contributing Factors / Situations : Environment - Non Weather Related



Narrative: 1

I was working a flight to LAS. I was the flying pilot. The flight was dispatched without an

alternate as one was not required. TAFs predicted wind gusts in the low 30 knot range. We

were given 1100 hold fuel.

The flight was proceeding without issue and the latest METAR reported gusts to 35 knots.

The winds were nearly aligned with runway 25L. We were expecting this runway for

landing.

Once we began out descent on the KEPEC STAR we began to experience continuous

moderate turbulence with occasional bursts of MOD-SEV. Unpleasant, but not unusual for

mountainous airports. We were also experiencing significant shifts in wind, especially as

we descended below the Front Range around the red rock area.

On downwind, we received a current wind report of approximately 48 knot gusts, nearly

aligned with the runway. At this point we decided it was safe to continue the approach as

the wind did not exceed aircraft limitations. On approach to 25L configuring the aircraft

was challenging, though not impossible. We were able to achieve a stabilized approach by

1000 feet.

On descent below 1000 feet, wind shifts became increasingly significant. At one time, I

was utilizing a near 30 degree crab for cross-wind to the left only to have it soon dissipate

and come from the right. Airspeed became increasingly more challenging to maintain,

even with significant over-ride inputs to the auto-throttles.

At around 200 feet airspeed, glide path, and descent rate became impossible to maintain,

the approach became unstable, and I initiated a go-around. On our climb out, I overheard

several other aircraft initiating go-arounds for wind shear from various runways. We even

overheard a 737 who was beginning their third attempt- a dangerous, unsafe situation to

place yourself in. In my opinion, LAS had become unsuitable.

At this point a decision had to be made. We were not dispatched with an alternate, but did

have some extra fuel. The closest suitable airport was ZZZ. We ran the numbers in the

FMS and calculated 2800 LBS on touchdown. Subtract an additional 500 LBS for approach

and potential en-route deviations and you end up with 2300 LBS. Below reserve fuel, but

certainly not unsafe. The First Officer (FO) and I discussed the options and determined a

diversion to ZZZ would be the safest course of action. This decision was solidified given

other aircraft had made several landing attempts without success and my confidence

another landing attempt would also result in failure. Given our fuel situation, one more

attempt would eliminate our chances of diverting.

The FO notified ATC of our intentions and I informed the flight attendants, passengers, and

dispatch of our situation and we continued to ZZZ.

We experienced continuous moderate turbulence for the entire flight with bursts of MOD-

SEV, especially as we descended through the mountain pass near the ZZZ1 area. On our

descent, we were told to maintain 210 knots. A significant wind shift again occurred and I

was forced to override the auto throttles to prevent a low-speed situation. In doing this, I

accidentally advanced the throttles into the MAX detent. I immediately returned them. This

was not intentional and was an error in my part.

We began to receive some vectors in the terminal area. Given our fuel supply, we advised

ATC of a min fuel situation per Flight Operations Manual requirements. This was prudent

as we did not want to be given further delays. ATC agreed.

We landed in ZZZ without issue and with approximately 2300 LBS remaining. We taxied to

the gate and deplaned to wait for Maintenance to clear the MAX thrust application. We

then boarded and continued to LAS with revenue PAX onboard in the evening after the

high winds subsided. We incurred a delay, but completed both flights.

Ultimately, I am glad we made the decision we did. Several aircraft in the LAS area

followed suit. Given the circumstances, it was certainly the safest course of action.

Synopsis

Air Carrier Captain reported that extreme winds at LAS created unsafe landing conditions.

The flight diverted to a nearby airport with more safe conditions and landed normally.

ACN: 1429176 (6 of 50)

Time / Day

Date : 201703


Place




Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : ZZZ





Flight Plan : IFR

Mission : Passenger


Airspace.Class B : ZZZ

Person

Reference : 1









Events


Anomaly.Deviation - Procedural : FAR






Assessments

Contributing Factors / Situations : Manuals



Narrative: 1

Upon arrival in the terminal area, as expected and briefed, we were in continuous

moderate turbulence from 14,000 MSL to the surface. We had briefed the FAs to be seated

early and informed the passengers early. We also briefed the severe windshear conditions,

other than instrument alerts and warnings requiring us to abandon the approach. The

captain elected to use Flaps 3 as suggested in the FM. I briefed the possibility of a high

pitch attitude tendency using Flaps 3, as well as, the visual illusion in the 10-7 pages

specific to this runway. We both discussed the fact this would be a safe firm landing and

would not try to finesse it because of the wind conditions and pitch tendency specific to

the configuration and runway. Automation was used to the [maximum] extent possible

and we followed the FM guidance for precautions in windshear areas (Minimum ground

speed, Flaps 3, additives on approach, etc.). We also made a plan for if a missed approach

was required as we had very little fuel if the need became a diversion to our alternate

(something we had discussed with Dispatch previously and would put us at 30 min of fuel

remaining at the alternate). We determined it was likely more prudent to attempt a second

landing if it became necessary and not proceeding to the alternate unless needed for

airport operations being suspended at our destination OR the first approach being

abandoned for unsafe conditions. The flight was dispatched with full tanks, allowing no

added fuel for more contingencies at arrival.

The approach proceeded as expected and we stabilized early using automation, additive

speed then Mini-GS. The captain kept the autopilot and autothrust on until approximately

200 ft when he disengaged the autopilot. At approximately 100-125 AGL we received a

reactive windshear warning in the final stage of settling the aircraft to the runway. The

energy state on the aircraft and proximity to the runway convinced me it was the safer

action to complete the landing from this position. The Captain and I agreed at the gate we

both felt the same regarding the aircraft position and energy condition and that it was the

correct decision. After the flight during our further debrief, we reviewed the Windshear

guidance even further and I realized there doesn't exist any relief in the FM for continuing

an approach with a reactive windshear warning and the operation thus was in violation of

the SOP. The Captain and I discussed that in essence his emergency authority was used in

that moment to bring the flight to a safe conclusion considering the position of the aircraft

when encountered and the options available (fuel state) if a missed approach was

completed.

Synopsis

A320 First Officer reported a windshear alert just prior to touchdown. They elected to land

rather than execute the windshear recovery as required by SOP.

ACN: 1428893 (7 of 50)

Time / Day

Date : 201703


Place




Aircraft

Reference : X

ATC / Advisory.Center : ZZZ


Make Model Name : EMB ERJ 170/175 ER/LR



Flight Plan : IFR

Mission : Passenger

Flight Phase : Cruise

Airspace.Class A : ZZZ

Person : 1

Reference : 1



Function.Dispatch : Dispatcher


Person : 2

Reference : 2






Events






Assessments



Primary Problem : Human Factors

Narrative: 1

I planned this flight according to company flight planning procedures. The flight was

delayed out of ZZZ due to winds and a one runway configuration resulting in lengthy taxi

times. Flight departed just above min fuel. As a result I was giving this flight additional

attention. Shortly after this flight was airborne I had another flight enroute to ZZZ1 that

made contact with me via ACARS concerning the fuel state. I ran numbers for that flight

and determined that the flight had burned 700lbs more than planned and was getting a

message upon calculation that "Insufficient fuel onboard". The determination was made to

divert that flight to add more fuel. At this point my concern increased for the Aircraft X

flight. It is a 3 hour flight so I was not overly concerned. I made arrangements for

diverting the ZZZ1 flight and then directed my attention to the ZZZ flight. Also at this time

the end of my shift was approaching. I requested the FOB (Fuel on Board) for this flight

and ran the numbers at ISO. The numbers returned with the message "Insufficient fuel

onboard". I do not remember exactly but 600-700 lbs under reserve at this point with

approximately two hours of flight remaining. My relief showed up and I briefed them on

the situation and advised them that a diversion was necessary due to the fuel remaining

onboard. I also discussed the issue with the ZZZ1 flight diverting due to higher than

planned fuel burn. I turned the desk over to the relieving dispatcher and while they were

getting logged on the desk I informed the coordinator and the duty manager of the

impending diversion. When I logged on the desk this morning I checked the flight and saw

that it did not divert and landed with 1500 lbs. This is a reoccurring issue with the

dispatcher that took over the flight not practicing effective flight following and flight

management. I looked back at the ACARS communication between the flight and the

dispatcher, it appeared that the dispatcher just resigned and accepted whatever the crew

said. The crew appeared to have a case of get there-itis based on the communication as

well. I can only do so much and expect that when flights are handed over to and accepted

by another "qualified" dispatcher that this type of situation does not occur.

Narrative: 2

2 hr hour delay. Took off at min fuel FOB 13.5, once at cruise winds aloft were stronger

than given out of the south at 180 knots. Winds died down in contact with dispatch the

entire time. We talked about diverting but weather was good and no delays. Landed with

1.4 without incident.

Synopsis

ERJ-170 Dispatcher and First Officer reported that due to strong headwinds flight planned

to divert; however, winds decreased and Crew proceeded to destination but landed with

less than reserve fuel.

ACN: 1428526 (8 of 50)

Time / Day

Date : 201702


Place



Environment

Flight Conditions : IMC

Light : Daylight

Aircraft

Reference : X



Make Model Name : EMB ERJ 170/175 ER/LR



Flight Plan : IFR

Mission : Passenger



Person

Reference : 1








Human Factors : Situational Awareness

Events




Detector.Automation : Aircraft Other Automation




Result.Flight Crew : Landed in Emergency Condition



Result.Air Traffic Control : Issued New Clearance

Assessments





Narrative: 1

We departed for ZZZ. Enroute, dispatch notified us that we had lost the alternate to

weather. I sent a message to confirm that we had a new alternate and were good to

continue. Dispatch confirmed ZZZ1 was our new alternate and that we had the numbers to

continue. When we reached ZZZ we shot the ILS to a missed. ATC vectored us back

around for a second approach. The second ILS ended in a missed approach. We requested

and were given direct ZZZ1. Enroute to the alternate the fuel levels went into the amber

range. We continued and when we were in contact with ZZZ1 approach control the fuel

went into the red range. Once the fuel reached the red range we [advised ATC]. A few

minutes later we landed in ZZZ1.

The flight plan was based on Weather that did not show visibility less than 6 miles and

ceiling below 700 ft. That day the weather went to 0/0.

Synopsis

EMB175 Captain reported diverting to the alternate airport after two missed approaches at

the planned destination.

ACN: 1427206 (9 of 50)

Time / Day

Date : 201702


Place

Locale Reference.Airport : RJAA.Airport

State Reference : FO


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : RJAA


Make Model Name : Widebody, Low Wing, 2 Turbojet Eng



Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS


Person : 1

Reference : 1














Human Factors : Confusion


Communication Breakdown.Party2 : ATC

Person : 2

Reference : 2















Events

Anomaly.ATC Issue : All Types










Assessments


Contributing Factors / Situations : Procedure

Contributing Factors / Situations : Chart Or Publication



Narrative: 1

Winds at RJAA were forecast to be 220/35 gusting to 46 knots and they were landing

runway 16R. Dispatcher had boarded fuel for us to arrive in the RJAA area with 38,000 lbs.

with ZZZZ as our primary alternate. The time to ZZZZ was about an hour with a burn of

13,300 lbs. I decided that when we got down to 30,000 lbs of fuel, it would be an

appropriate time to divert to the alternate if needed. After holding at several fixes and

extensive vectoring for approximately an hour and fifteen minutes, we shot an approach to

runway 16R. At about 500 ft, we got a significant increase in airspeed, followed by a wind

shear alert. We performed a wind shear escape maneuver with a missed approach. We

immediately decided to go to our alternate due to fuel considerations. We were held at a

low altitude and vectored away from our alternate until we were out from the RJAA normal

air traffic routes. We had conferred with our dispatcher as to where he wanted us go if

needed and ZZZZ had been agreed upon. Each new controller was notified that we were a

minimum fuel aircraft and needed expedited handling. We requested direct to the outer

marker of the ZZZZ runway. Communication was difficult and ATC was relatively

uncooperative. Forty miles from the airport, we were notified that distance to landing was

140 miles. The Japanese air traffic control refused to allow us direct to the airport unless

we declared an emergency even though there was minimal air traffic at ZZZZ. At that time

we had approximately 15,600 lbs. of fuel. We landed with approximately 12,900 lbs of fuel

and parked. Block time was 15 hours and 59 minutes. Our Dispatcher, who is one of our

more experienced, had the foresight to have us arrive in Tokyo having 38,000 lbs. of fuel,

recognizing that this day we might really need it.

Narrative: 2

[Report narrative contained no additional information.]

Synopsis

Air carrier flight crew reported they experienced a windshear alert on final to RJAA,

executed a go-around, and diverted.

ACN: 1427048 (10 of 50)

Time / Day

Date : 201702


Place



Altitude.MSL.Single Value : 33000

Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : B737-900



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS




Component

Aircraft Component : Fuel Quantity-Pressure Indication



Person : 1

Reference : 1











Human Factors : Troubleshooting


Person : 2

Reference : 2










Human Factors : Distraction




Events






Result.General : Maintenance Action



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

Assessments



Narrative: 1

After level off at FL330, turned off seat belt sign, and made PA. Shortly after, FO noticed a

fuel imbalance of about 2,000 lbs and noted left main tank fuel indicator decreasing

approximately 100 lbs every 30-60 seconds. Center tanks empty and had secured center

tank pumps earlier. Ran QRH fuel leak checklist and discovered cross feed valve open.

Closed cross feed valve and noted fuel continued to decrease at the same rate. Discussed

diversion airports with FO. Handed over ATC comms to FO and instructed her to start

towards divert airport. Weather was clear. Notified FAs diverting for possible fuel leak, 15

mins to landing, no special instruction or evacuation preparations, turned on seatbelt sign,

made PA, sent ACARS message to dispatch, and asked commuting pilot in the cabin to

visually inspect left engine/wing for a fuel leak. They reported back no leaks noted.

Continued QRH Fuel Leak checklist down to Engine Shutdown. I paused and handed the

QRH to FO and took over Pilot Flying duties.

Reviewed current ATC clearance and distance from the divert airport. FO re-ran the QRH

Fuel Leak checklist. Slowed aircraft to 250 KIAS, then 220 KIAS while following vectors

and attitude assignments from ATC and continued to diagnose fuel leak. Left main tank

fuel indications continued to decrease at the same rate. ATC relayed current airport

weather. Paused FO with QRH at Engine shutdown to brief visual approach backed up by

ILS, FMC programming, and setup flight instruments and frequencies. We also briefed

Engine Out approach which required an ATC delay vector to accomplish this then

continued vectors to intercept ILS. Configured and intercepted LOC/GS and proceeded to

runway visually. Continued QRH with securing the left engine and the rest of the QRH. FO

was most of the way thru the One Engine In-Operative Landing checklist (stopped at

"Wing Anti-Ice Not Required") but due to proximity to the airport (1500 AGL) I elected to

continue approach and landing and forego the rest of that checklist. Wanted to

concentrate on safely landing the aircraft. Landed without incident, taxied clear and

stopped for Fire/Rescue to inspect aircraft. Received all clear and taxied to gate. Fire/

Rescue recommended we deplane the aircraft at the gate as Maintenance inspected the

aircraft. Complied and debriefed with maintenance and dispatch. Aircraft inspected by

Maintenance, cleared, and returned to service. Deadheaded on the same aircraft for the

next flight. After landing, follow-on pilots noted similar fuel decrease on left main tank

indicator on climb out. The fuel issue written up and aircraft taken out of service.

Narrative: 2


Synopsis

B737 flight crew reported a fuel leak was discovered in flight and the crew elected to

divert. Maintenance determined an aircraft fuel quantity indication anomaly was the cause.

ACN: 1426762 (11 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.ARTCC



Environment


Weather Elements / Visibility.Visibility : 10

Light : Night

Aircraft

Reference : X


Make Model Name : Cheetah, Tiger, Traveler AA5 Series



Flight Plan : None

Mission : Training

Nav In Use.VOR / VORTAC : VOR


Airspace.Class E : ZZZ

Airspace.Class G : ZZZ

Component : 1

Aircraft Component : Engine


Problem : Failed

Component : 2

Aircraft Component : Fuel Selector


Problem : Design

Problem : Improperly Operated

Person

Reference : 1



Reporter Organization : FBO

Function.Flight Crew : Instructor


Qualification.Flight Crew : Multiengine

Qualification.Flight Crew : Commercial

Qualification.Flight Crew : Flight Instructor

Qualification.Flight Crew : Instrument


Experience.Flight Crew.Last 90 Days : 135






Human Factors : Training / Qualification





Events






Result.Flight Crew : Became Reoriented

Result.Flight Crew : Inflight Shutdown


Assessments





Narrative: 1

While on the inbound leg of the procedure turn for the VOR-B Practice approach, a fuel

imbalance was noted. The instructor made the decision to switch fuel tanks, and notified

the student that this should be done. This action was not observed due to scanning outside

for traffic as the student was under the foggles. After approximately 30 seconds, the

engine failed due to fuel starvation, as the fuel selector was placed into the off position

inadvertently by the student who was task saturated and had initially trained on a 172,

where tank imbalances were rarely a problem. After unpowered flight for approximately 30

seconds, the instructor realized the problem, and put the fuel selector onto the left tank.

Afterwards, the aircraft was then flown to it's home airport after an assessment of the

situation revealed no further issues with the engine.

This could have been prevented in a number of ways, namely that the fuel tank switch

should have been observed by the instructor, the student should have been briefed on this

topic specifically, and the tank switch could have been done in a non-critical phase of

flight. These items should be at least brought up in future instructor training, as it could

easily happen across aircraft types, and can lead to significant issues.

Synopsis

A Flight Instructor reported his instrument student moved the fuel tank selector to the OFF

position while attempting to change engine fuel sources. The Instructor determined the

engine failure cause and restarted the engine.

ACN: 1426386 (12 of 50)

Time / Day

Date : 201702


Place



Environment

Flight Conditions : Mixed

Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 900 (CRJ900)



Flight Plan : IFR

Mission : Passenger

Nav In Use : GPS




Person

Reference : 1











Events

Anomaly.Deviation - Procedural : Other / Unknown





Result.General : None Reported / Taken

Assessments




Narrative: 1

When we were climbing out, I overheard that many different aircraft were leveling off

early when they were unable to climb to their requested final. Both me and the captain

looked at the FMS and saw in the climb the temperature was between ISA+15 and

ISA+25. This caused us to burn through a lot of our extra fuel and even through we took

off about 900 pounds over Min Fuel, between this and the Speed Restrictions going into

ZZZ and the 45 mile downwind we had in ZZZ (I saw ZZZ1 out the window we were that

far out) we landed just under our reserve fuel.

The atmospheric conditions and ATC constraints made us burn through about 2,000 more

pounds than we originally planned. The flight was never in jeopardy and we discussed that

if there was any reason we were pulled off the approach or went around, we would

immediately declare Min Fuel, but it was just a combination of many different things that

led to such high fuel consumption.

Synopsis

A CRJ-900 First Officer reported a fuel burn of approximately 2,000 pounds over planned

because climb temperatures were between ISA+15 and ISA+25 coupled with ATC delays.

ACN: 1426149 (13 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : SCT.TRACON

State Reference : CA

Environment


Aircraft

Reference : X


Make Model Name : B737 Undifferentiated or Other Model


Mission : Passenger


Route In Use.STAR : SETER4

Person : 1

Reference : 1









Person : 2

Reference : 2







Events








Assessments



Narrative: 1

Enroute to PSP the forecast weather for ONT, LAX and PSP were checked. I informed the

First Officer (FO) we would use ONT as a divert if need be and entered it as an alternate

destination in the FMS. Approximately 1 hour out I entered the SETER4 arrival to 26R in

Route 2. The actual weather and forecasted weather for PSP was ok, however, we only

had enough fuel for one approach and enough fuel to make it to ONT and land with

reserve fuel.

Inbound to the arrival at PSP we were advised, due to traffic, we would need to hold

present position. When we queried ATC for an expected arrival time they were unable to

give us one, other than stating (1) aircraft just did a go-around at PSP and two other were

in sequence for the arrival. ATC could not give us a reason for the go-around. On the

assumption, we might be diverting, I attempted to contact dispatch, no joy. I immediately

followed up with an ACARS message to dispatch requesting ONT as an alternate. Not long

after I sent another ACARS message requesting the same. After 2 turns in holding and

some vectoring, we reached my bingo fuel and I directed the FO to advise ATC and

request ONT as a divert. We previously declared minimum fuel in holding. Not long after I

noticed dispatch had issued ONT as a divert.

ATC cleared us directly to PSP and the SETER4 arrival 26R. To be able to activate and

execute Route 2 saved us valuable time during a very busy evolution. Enroute to PSP I

filled out and sent an ACARS divert message to dispatch. We landed ONT uneventfully,

however, they were not aware of our divert situation.

Lessons Learned:

- I've never been afraid to add fuel nor have I ever been denied. My fuel load was normal

for normal day at PSP but, the weather at PSP was not the norm. After my initial pre-

flight, I was leaning towards adding fuel, however, I allowed distractions to dictate

otherwise. Unacceptable!

- At a minimum I should have had dispatch add ONT as an alternate.

Narrative: 2

Enroute to Palm Springs we were informed that Palm Springs was in a situation of

"airspace saturation". We were given a hold clearance and an EFC time. The flight was

planned without an alternate airport and some hold fuel. I was the pilot monitoring so I

asked ATC to clarify what they meant by airspace saturation and give us a better idea of

why we were holding. We were told aircraft were not getting in to the airport due to

weather. After looking at the situation and calculating our options based on the fuel we

had, we asked dispatch to add Ontario as an alternate airport and send us recalculated

fuel. We did not get a reply from dispatch before we decided the situation warranted

starting the diversion to Ontario. As Ontario was not on the flight plan or fuel calculation

as an alternate we decided in an abundance of caution to divert to Ontario. Soon after the

diversion was started we received updated fuel information from dispatch. We flew to

Ontario and landed with sufficient fuel, the flight was uneventful.

Synopsis

B737 flight crew reported diverting to a nearby alternate when the weather at destination

started to cause missed approaches. The forecast at departure did not require an

alternate.

ACN: 1425891 (14 of 50)

Time / Day

Date : 201702


Place




Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : PA-28R Cherokee Arrow All Series



Flight Plan : None

Mission : Training

Flight Phase : Takeoff

Airspace.Class D : ZZZ

Component

Aircraft Component : Fuel Drain


Person

Reference : 1












Events




When Detected : Taxi


Result.Flight Crew : Rejected Takeoff

Assessments



Narrative: 1

CFI candidate was previously flying with a different instructor in the Arrow (PA-28R-200)

at our flight school for the commercial pilot certificate. Plane was topped off with fuel just

prior to our flight, and fuel was drained. We did taxi and runup normally (although

previous instructor had CFI candidate use a different method than the checklist to start the

engine, by using full throttle to prime the engine and shutting off fuel pump before

starting). After runup, CFI candidate performed pre-takeoff checklist. During pre-takeoff

checklist, CFI candidate changed fuel from right tank to left tank. I told her she wasn't

"wrong" to do so (so long as fuel was properly drained during preflight), but normally we

don't change tanks then because if there is a problem with the fuel or contaminants or

water in the other tank, we don't want to find that out during our takeoff climb. We got to

the end of the runway and gave full throttle, powered up normally, and then as we were

rolling lost a significant amount of power (on the order of losing 50%-75% of our power).

Exited the runway and taxied back to base. Mechanic did thorough and extended runup

and said everything is OK, probably just some water in the fuel (on several previous

flights, I have found small amounts (2-3 tablespoons?) of rust-colored water from the left

tank, probably came from the fuel truck and is difficult to remove from the airplane. From

what I can tell, this plane's left tank is the only plane in our fleet that has this rust-colored

water coming from it, albeit small amounts and only rarely). Chief of flight operations took

the plane for a test flight after the mechanic's extended runup and declared everything

OK. Question - if there is some water from the fuel truck in the left tank, how can we

remove it if repeated draining don't remove it? Corrective actions - don't switch tanks after

runup, and make sure to drain at least a full fuel cup at each fuel drain during preflight.

Synopsis

Piper PA-28 flight instructor reported an aborted takeoff due to loss of power.

ACN: 1425841 (15 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment



Light : Daylight

Ceiling.Single Value : 16500

Aircraft

Reference : X

ATC / Advisory.TRACON : ZZZ

Aircraft Operator : Personal

Make Model Name : PA-28 Cherokee/Archer/Dakota/Pillan/Warrior


Flight Plan : None

Mission : Personal


Route In Use : Direct


Component

Aircraft Component : Fuel System



Person : 1

Reference : 1



Reporter Organization : Personal


Qualification.Flight Crew : Private








Person : 2

Reference : 2















Events

Anomaly.Aircraft Equipment Problem : Critical






Result.Flight Crew : Overcame Equipment Problem

Assessments



Narrative: 1

While cruising we began to have an issue with the engine. I was flying right seat, with [a]

safety pilot [in the] left seat. It started to sound like the engine was losing power. [The

safety pilot] took over flight controls, we pitched for glide airspeed and turned back

towards the runway. Following the emergency checklist, at about 1800ft MSL, we

determined that we had run out of fuel in the left tank. After turning the fuel pump on,

switching tanks, the engine ran at normal operation. We proceeded without incident. Upon

evaluation of the flight, we determined that our personal conversation led to the

distraction of using the checklist. Moving forward, all checklists will be completed and

double checked to ensure this will not happen again.

Narrative: 2


Synopsis

Two pilots in a PA28 reported they experienced a power loss when they ran a tank dry

while engaged in conversation.

ACN: 1425423 (16 of 50)

Time / Day

Date : 201702

Place



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Fuel Distribution System



Person

Reference : 1









Events







Assessments



Narrative: 1

At cruise we received an ECAM alert that indicated we had LOW FUEL in the left outer (LO)

tank. That tank showed to be full (8.2). We ran the QRH and it directed us to use our

inner, center and trim fuel in the manual mode and then open the cross feed and burn

from our outers until landing. We notified Maintenance Control of our issue and assumed

they would forward the information to Maintenance (MX). WE WERE WRONG...THEY DID

NOT. As the center and inner tanks ran empty the outer tanks began to feed. We soon

noticed that the LO tank was not really showing an indication of consumption. The split

between the outer tanks began to approach the balance limits. We were approximately 80

miles out and had no choice but to let the tanks continue to feed the way they were and

leave the cross feed open. The split began to go out of limits as we requested direct to the

final approach fix and min delay. We had to adjust the trim a couple of times, which

indicated we may actually not be burning fuel out of the LO.

We landed with 7.8 in the LO and 4.8 in the RO. ASSUMING MX had been told about out

problem we blocked in and shut down the engines. Before MX came to talk to us they

began to move fuel around in the tanks. This prevented us or MX from being able to

determine if we actually had a tank that didn't feed or if we just had an indicator issue. I

recommended to the captain taking the plane from me that he not take the aircraft unless

he could get enough fuel in the Inner tanks to get him back without using either of the

outer tanks. If the LO tank was in fact NOT burning fuel we landed with less than 5000

LBS of useable fuel. But we may never know now. It was good fortune that I added 3000

LBS of fuel to the release.

Synopsis

Air Carrier Captain reported a problem with the fuel tank distribution system resulting in

near out of balance limits. Flight landed without incident.

ACN: 1425364 (17 of 50)

Time / Day

Date : 201702


Place




Environment


Light : Daylight

Aircraft

Reference : X


Aircraft Operator : Air Taxi

Make Model Name : PA-31 Navajo/Chieftan/Mojave/T1040



Flight Plan : IFR



Component

Aircraft Component : Fuel Pressure Indication



Person

Reference : 1



Reporter Organization : Air Taxi






Events






Result.Flight Crew : Returned To Departure Airport


Assessments



Narrative: 1

Enroute ZZZ to ZZZ1 in IMC conditions, a right fuel annunciator illuminated. After turning

on the boost pump, changing fuel tanks and checking gauges the fuel pressure and fuel

flow continued to be erratic and unreliable. I then proceeded to secure the right engine,

[advised] ZZZ Center and returned to ZZZ where VFR conditions existed and emergency

personnel and equipment were available.

Synopsis

PA-31 Captain reported an issue with the right engine fuel pressure during cruise. Captain

secured the engine and returned to the departure airport.

ACN: 1425275 (18 of 50)

Time / Day

Date : 201701


Place

Locale Reference.Airport : MIA.Airport

State Reference : FL


Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : MIA





Flight Plan : IFR

Mission : Passenger




Airspace.Class B : MIA

Component

Aircraft Component : FMS/FMC



Person

Reference : 1








Events






Assessments



Narrative: 1

During approach briefing, we briefed the approach to RWY 26R in Miami. We also briefed

the possibility of moving to RWY 26L if it was available. The brief was to use full flaps on

the short runway (26R) and flaps 3 if we were able to sidestep to the long runway (26L).

Having done this probably a hundred times in every other airplane I've flown, the one

thing we neglected to brief was the necessity of changing the Perf page and the flap 3

button.

During the last 1000 feet the airplane started squawking at us for not having selected full

flaps to match the selection of the button.

I saw what had happened and also saw we only had a little over 6,000 LBS of fuel

remaining. I asked First Officer to continue the approach and selected full flaps to quiet

the aircraft yelling at us. I felt uncomfortable with the thought of going around at this fuel

level which was the reason I asked him to continue.

This was the first time I had done this sidestep maneuver in this model aircraft. It was a

learning experience because I found this aircraft requires too much computer work to even

consider attempting this type of maneuver again. Having easily performed this so many

times, I just wrongly assumed that it was this easy to accomplish in this airplane.

It takes too much work to attempt this type of maneuver this close to the airport. I will not

attempt this again in this model airplane.

Synopsis

A319 Captain reported a GPWS warning for flap setting following a side step maneuver to

a longer runway.

ACN: 1424199 (19 of 50)

Time / Day

Date : 201702


Place



Environment


Light : Night

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger


Flight Phase : Parked


Route In Use : Oceanic


Person : 1

Reference : 1



Function.Dispatch : Dispatcher

Qualification.Dispatch : Dispatcher


Human Factors : Other / Unknown

Person : 2

Reference : 2











Events




Detector.Person : Dispatch



Assessments



Contributing Factors / Situations : Equipment / Tooling

Primary Problem : Ambiguous

Narrative: 1

Due to the payload and weight limitations, I planned a flight as a Redispatch Flight, with a

total fuel of 309,910 lbs and a planned arrival fuel of 19,946 lbs, which included 2000 lbs

of Dispatch Add fuel and 15 minutes of Hold fuel. Normally on a redispatch flight I specify

a fuel load instead of add fuel to dispatch add, to allow for a "Redispatch Buffer", however

due to limitations of the Flight Planning system, I was unable to do so on this particular

flight, because if I had done so the system would not calculate a flight plan. Planned fuel

at the flights redispatch point was 49,399 lbs.

When I walked in for my shift the next morning, I learned that the flight had overburned

by 4000 lbs and had only approximately 45,000 lbs at his redispatch point. Furthermore,

the dispatcher who was running the analysis at the redispatch point ran several scenarios

to try to get a redispatch fuel without success. Because of this, the flight nearly diverted.

After a group discussion of qualified dispatchers, the dispatcher was finally able to get a

point aloft flight plan to run, which provided sufficient fuel for redispatch. I looked at the

flight after the incident and found that planned numbers on the flight were lower than the

Dispatch release by nearly 2000 lbs. Given the tightness of these ultra-long haul flights to

begin with, this is very concerning to me.

Narrative: 2


Synopsis

Air carrier Dispatcher and First Officer reported an issue with the company dispatch

computer system which does not reflect accurate fuel burns on specific international flights

and sometimes jeopardizes legal re-dispatch points.

ACN: 1423944 (20 of 50)

Time / Day

Date : 201702


Place




Environment


Light : Daylight

Aircraft

Reference : X

Aircraft Operator : FBO

Make Model Name : Cessna 150



Flight Plan : VFR

Mission : Personal



Component

Aircraft Component : Fuel



Person

Reference : 1





Function.Flight Crew : Single Pilot









Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown

Anomaly.Deviation - Procedural : Landing Without Clearance







Assessments



Narrative: 1

I'm a low-time commercial pilot building hours on my own to get to a full time job. My

single-engine training (and much of my personal flying since) was almost exclusively in

Grumman Cheetahs, but I've started renting 150/52s from a different school in the last

few weeks to save some money while building time. To get checked out with them, I did a

tailwheel endorsement in their converted 152, including a good number of takeoffs and

landings on grass. Before the incident described below, though, I did already have about

10 hours in the nose wheel 150 involved.

One of the jobs I've talked to in the past few months told me to get in touch again once I

had 400 hours. Being about ten short of that, I set out this weekend to be able to finally

email them back next week by taking a roundabout trip [to multiple locations] to get

lunch. I was trying to get off pretty early to make it to [my destination] before dark, since

ceilings were marginal there and none of the 150/52s are equipped with GPS, and I'm still

reacquainting myself with navigation solely by VOR. But while I was pre-flighting, the

owner and head instructor of the school showed up, so I got to talking over my plans with

him briefly. He mentioned ZZZ usually had avgas for a steal, and that the 24 gallons I was

starting out with should be enough to get me to ZZZ1 then halfway back to ZZZ, where I

could pick up enough fuel to make it all the way down to [my destination]. (This particular

plane has long-range tanks, just barely shy of 40 gallons.)

The flight up was uneventful. In ZZZ1, I dipped the tanks and showed six gallons per side

still. I assumed if I had made it the whole way there from [my departure airport] on just

half of what I started out with, I could easily make it halfway back before refueling.

The first thing that gave me pause was that both gas gauges were pegged at empty when

I started up. (It certainly made me miss the Shadin fuel computers I'm used to in my

regular Cheetahs.) But I had literally just seen the gas in the tanks with my own eyes, so I

trusted my arithmetic and set off. Still, those two gigantic E's staring at me from the gas

gauges convinced me to fly at economy cruise at least half the way to ZZZ. At that setting,

though, I was seeing a groundspeed in the mid-40-knot range, and my estimated time en

route ballooned from one hour and 20 minutes to close to three hours--which should have

been my first gigantic red flag. About halfway there, the needle on the right gas gauge

started to bounce off of empty, which inspired me to go back to full power, pushing my

groundspeed into the 70s. I was feeling more confident in my mental fuel calculations,

despite the wind. Before long (relatively speaking), I was approaching ZZZ2, about ten

miles north of ZZZ. To see the airport practically within gliding distance melted my last bit

of unease about fuel right about the time Center sent me to the advisory frequency. I

called ZZZ traffic on a four-mile final, but within 60 seconds the engine started to sputter.

I pumped the mixture and throttle to see if it was just a hiccup, then once I was convinced

low fuel was the actual problem, I wagged the nose up and down to see if I could re-port

the last few drops. But at about 1500 feet and two miles from the runway, the engine

stopped for good. I felt overwhelmed for about a second, but then accepted that it was

actually happening and that I was going to have to decide what to do. I quickly went back

to Center so someone would know to come looking for me in case I was knocked

unconscious, but I was already too low for them to receive me. For a few seconds, it

looked like I might actually be able to make the runway, but the 20 knot headwind quickly

made it apparent that wasn't possible. In fact, it became pretty clear that the field directly

in front of me, was where I was going to land. It looked like very neatly planted curving

rows of short grass, with apparent furrows between the rows, and ridges about five feet

from top to bottom spaced maybe 100 feet apart. I was amazed at how steeply I had to

nose over to maintain best glide speed, I guess because of either the strong headwind or

the wind milling propeller, which sure seems to create a lot more drag than the engine

pulled to idle as I was used to it from training. Still, I managed to flare and touch down

pretty gently, all things considered, and came to a stop very shortly.

Not long after shutting down, calling the airport for help, and thanking God that everything

had gone as well as it had, the farmer whose field I had just made a runway pulled up to

the gate along [the highway] and drove out to greet me. He had heard me lose power and

seen me coming down, although my actual landing was obscured from his vantage point at

his house in the southwest corner of the field. He said he was afraid he was going to find a

flipped plane when he got out to the see what had happened, but was quite calm and

friendly when he saw me walking around and that nothing seemed damaged. He informed

me that there were cows in the field that might come by to see the plane, and that I

should call him if I needed help with anything. My hope was that I'd be able to get some

gas and take off again from the field, and I thought I might need him to corral the cows,

which I had yet to see anywhere around the part of the field I had landed in. I gave him

my number and told him to let me know if there was any damage to the field, but he

didn't seem at all concerned about that, although he did say he'd appreciate a call before I

took off so he could come watch.

He left, while I waited for the airport manager, who had sounded very concerned and

ready to come help as quickly as possible when I had talked to her on the phone, although

she wasn't sure what to do about gas. She called one more time to confirm exactly where

I was, but just before she arrived, the farmer came back with his wife and granddaughter

to see how things were going. When the airport manager did arrive, she had a man with

her as well, who turned out to be a doctor and himself a pilot with lots of experience

landing and taking off from fields, a rather happy combination for someone who finds

himself in the situation I was in. They had brought two five-gallon cans of avgas, but

before we even bothered with that, he looked the plane over and started scanning the field

for the feasibility of getting back in the air. I had been thinking about the length of the

field--the farmer had told me it was about half-a-mile--as well as the the upward slope

from north to south, the direction into the wind; but he pointed out that the terracing

presented a real danger of a prop-strike as I picked up speed, which would not have

occurred to me. (He noted that there were no signs on the propeller of any contact from

the landing, which I assume I would have noticed had it happened, but it was reassuring

to hear it from a clearly more experienced pilot who knew what to look for.) We walked

and drove all around the upper portion of the field, and scouted a route that seemed

feasible. It started on one crest, moved diagonally down and up the next, then curved to

the right to stay on top of that ridge as it bent due south directly toward a line of trees

(and more into the wind), a small billboard, and [a highway].

After talking over short-field technique and the particular importance of getting and

keeping the nose wheel up as I accelerated down one crest and up the next, we (mostly)

emptied one gas can into each wing, swung the plane around by hand to get it facing the

starting point we had decided upon, and I got the engine going and taxied back while the

airport manager and the pilot drove their car to a point along my path at which I would

abort my takeoff if I didn't seem to be getting airborne. After a run up, I held my brakes,

revved the engine all the way up, and embarked on my curved take-off path. I got down

the first ridge and up the second without any problems or prop strikes, by which point the

plane was starting to feel light on its wheels. As I passed the car, only my right wheel was

on the ground as I lowered my right wing into the wind and finished my turn southward.

Shortly thereafter, I was completely off the ground, and I lowered my nose to point

directly at the billboard as I gathered speed. The poor 150 does not feel athletic, but it

does feel light, and I was confident by this point that I was going to be able to climb over

any of the obstacles in my path, however meagerly. And indeed, I gave the interstate

quite a show, being surely no higher than 200 feet over the passing cars. Within a minute,

I was touching down on runway XY at ZZZ, and another minute later was refueling at the

much more conventional self-serve pumps.

The whole experience left me with several strong impressions. First of all, all the clich??

you hear training for your private certificate and in case studies are true. When the engine

first seized, so did I, refusing to believe what was actually happening. Once I overcame

that, I had to convince myself as the headwind pushed the airport out of reach that I was

not going to stretch my range enough to make a still embarrassing but ultimately much

less consequential landing on the runway. I actually took the time to think to myself in

that moment how inconvenient this off-airport landing was going to be. Realizing the

ridiculousness of that concern in the face of a still very potential crash landing, I did what I

had been taught to do, even though it felt very different than any of the simulations I had

done with an instructor sitting next to me. As I've already mentioned, the downward

attitude necessary to maintain glide speed was far more dramatic than I would have

expected, but I'm exceedingly glad I committed to it.

When I had a little more time to decompress back at the airport and on my return flight,

the precarious balance of bad luck versus good luck really struck me. On the bad side, if

the winds had been a little bit weaker, if I had stayed at my economy cruise setting a little

longer, heck, if I had left with two more tablespoons of fuel in the tanks, I might have had

a moment of fear when I fit a whole 40 gallons in my tanks while refueling at the airport,

but the experience would have been much easier to forget in the long run. But of course,

when I say bad luck, I really mean bad planning and dangerous assumptions on my part

as PIC. (As my wife quoted me from months before when I told her all this after getting

home from this long day's journey: "There's no excuse for running out of fuel.") The good

luck really is amazing, though: at 1500 feet AGL with a 20 knot headwind, my only real

decision was to execute a forced landing on the beautiful field right below me, or crash

trying to make it to the runway; if I had been at an airport surrounded by trees, there

would have been no outcome as neat and tidy as what I experienced today. Of course, the

mere fact that almost all of my flying is within the [local area] means I often have a nice

field below me to land on. Or if I had been less cautious and tried to fly the whole way at

high-speed cruise, I might have ended up in a field far less convenient than one mile from

my intended fuel stop, right by two big highways, between two towns, and within

cellphone reception. And how could I have possibly planned a forced landing a mere phone

call away from an experienced pilot with an extensive history flying in and out of soft-

fields, an airport manager all too happy to help out an embarrassed pilot, and a farmer

undeservedly unconcerned about a little thing like an airplane scratching up his field.

Synopsis

A pilot of a Cessna 150 reported that he ran out of gas prior to reaching the airport.

ACN: 1423725 (21 of 50)

Time / Day

Date : 201702


Place




Aircraft

Reference : X



Make Model Name : Medium Transport



Flight Plan : IFR

Mission : Passenger

Flight Phase : Initial Approach


Person

Reference : 1








Events







Result.Air Traffic Control : Issued Advisory / Alert

Assessments




Narrative: 1

We were dispatched to ZZZ with an ETA of XH06. At our time of departure, the TAF at ZZZ

read as follows:

XYXA26 XYXA/XXXG 34005KT P6SM OVC007

FMXYXF00 34004KT P6SM SCT012 SCT120

FMXYXH00 29010KT P6SM SCT020 SCT050

FMXXXN00 30006KT P6SM VCSH BKN015 OVC050

FMXXXT00 VRB05KT 6SM -SHRA BR SCT010 OVC015

FMXXXE00 VRB05KT 6SM BR BKN015

Based on our ETA, no alternate was required, but I decided to monitor the ZZZ weather en

route in case we needed to develop a contingency plan. As we proceeded to ZZZ, METAR

reports indicated low ceilings persisting at ZZZ. We also received a TAF en route that

indicated deteriorating weather at ZZZ, so I sent a free text to dispatch requesting an

alternate. Dispatch added an alternate of ZZZ1 and we amended the paperwork

accordingly. I also elected to reduce our cruising speed to long range cruise in an effort to

save fuel. As we drew closer to ZZZ, METAR reports indicated improving weather. The last

two METAR reports we received prior to arrival read as follows:

ZZZ 10XF06Z 00000KT 7SM SCT005 BKN250 17/14 A3004 RMK AO2 T01670139

ZZZ 10XF51Z 19003KT 10SM FEW005 FEW160 BKN200 BKN250 19/13 A3004 RMK AO2

SLP171 T01890133 10189 20144 50009

Based on these reports, I planned to execute a visual approach backed up with the RNAV

approach to runway 27. At that time, all other aircraft were landing successfully at ZZZ. As

we began the final approach segment, [an] aircraft ahead of us on the approach indicated

that they were going missed. We continued the approach down to minimums, but also had

to execute a missed approach. We completed the go-around procedures and checklists,

and I notified the Flight Attendants (FA) and made an announcement to the passengers.

At this time, I believe we had around 3600 lbs. of fuel aboard. Based on the weather

information we had and our low fuel status, I decided that the safest course of action was

to attempt the ILS to runway 9 ZZZ. As we were being vectored on to the approach, the

tower reported wind was 290 at 10KT, which we determined was within the tailwind

limitation for the aircraft. Given the tailwind, I elected to conduct a flaps full approach in

order to minimize the landing distance required. As we began the final approach segment,

the tower issued a wind report of 300 at 13G17KT, which is well outside the tailwind

limitation. At that time, we decided to discontinue the approach and proceed to the

alternate of ZZZ1, and declared minimum fuel. Since we were west of ZZZ at the time, I

suspected that from our present position ZZZ2 might be closer than ZZZ1. The First

Officer (FO) checked the weather at ZZZ2 and found that it would allow us to land, so we

queried ATC as to which airport was closer. ATC said that ZZZ2 was closest to us, so we

elected to go there instead of ZZZ1. I notified dispatch of our intentions, and the

dispatcher suggested we land at ZZZ3, as it was 30NM closer to our position than ZZZ2.

We checked the weather at ZZZ3 and found it acceptable, so we elected to go there and

declared [minimum] fuel. I notified dispatch of our intention to land at ZZZ3, and they

coordinated with ZZZ3 operations, and provided us with weather and NOTAMS. I briefed

the flight attendants that we would be conducting a [minor emergency] and landing in

ZZZ3, and made a PA to inform the passengers of the diversion. While just outside of

LEMON at 2400 feet and intercepting the glide path for the ILS 20R ZZZ3, the tower

issued a low altitude alert, but we had captured the glide slope. The FO informed the tower

of this. We conducted a successful ILS approach to Runway 20R at ZZZ3 and landed

without incident. We arrived at the gate in ZZZ3 with 1450 lbs. of fuel aboard.

Synopsis

Air Carrier Captain reported a missed approach due to weather which ultimately resulted in

a diversion due to low fuel.

ACN: 1423633 (22 of 50)

Time / Day

Date : 201702


Place

Locale Reference.Airport : SAN.Airport



Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : SAN


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



Flight Plan : IFR

Mission : Passenger


Nav In Use : GPS


Route In Use.Other

Airspace.Class B : SAN

Person : 1

Reference : 1











Person : 2

Reference : 2










Events







Assessments



Narrative: 1

Dispatched to SAN with no alternate required. Upon arrival, conditions on the ATIS stated

MVFR. Started nonprecision approach to Runway 27. Went missed approach due to low

ceiling. ATC offered Runway 09, but the tailwind component was greater than our limits

would allow. Contacted dispatch and mutual agreement to divert to ZZZ. Landed at ZZZ.

Narrative: 2


Synopsis

Air carrier flight crew reported flying a missed approach while attempting the SAN RNAV Y

Runway 27 due to weather.

ACN: 1422923 (23 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZOA.ARTCC



Aircraft

Reference : X

ATC / Advisory.Center : ZOA

Aircraft Operator : Military

Make Model Name : F/A 18 Hornet/Super Hornet


Flight Plan : IFR

Mission : Tactical


Route In Use : None

Airspace.Class A : ZOA

Person

Reference : 1

Location Of Person.Facility : ZOA.ARTCC

Reporter Organization : Government

Function.Air Traffic Control : Enroute

Qualification.Air Traffic Control : Fully Certified

Experience.Air Traffic Control.Time Certified In Pos 1 (yrs) : 7







Human Factors : Training / Qualification


Human Factors : Human-Machine Interface



Events

Anomaly.Airspace Violation : All Types






Assessments

Contributing Factors / Situations : Airspace Structure


Primary Problem : Procedure

Narrative: 1

Parties involved were ZOA Sector 14, Fleet Area Control and Surveillance Facility

(FACSFAC) San Diego, and a Fighter Wing from California. Aircraft X showed up as a Mode

C intruder in sector 14 airspace with no info or handoff. Aircraft X showed with minimum

fuel in sector 14 airspace no info on this until he was already there and the D-SIDE

questioned FACSFAC on this. Aircraft X was a late handoff already in sector 14 airspace.

Communications and intentions were not figured out until all these aircraft were in sector

14's airspace.

Fighter Wings routes of flight and altitudes were conflicting with multiple pieces of traffic

landing SJC or overflying sector 14's airspace. Had no communications or intentions been

established prior to the fighter wing crossing this very busy corridor of sector 14 there

could have been a loss of separation. Sector 14 D-SIDE was doing everything in his power

to keep these aircraft from entering our airspace. FACSFAC repeatedly does not

understand what unable to take a point out or handoff. They questioned it several times

during this session. If you're working this type of scenario and the sector next you cannot

take a handoff what makes you think a point out will be accepted.

FACSFAC San Diego continues to allow these fighter wings to operate right on the

boundary of Sector 14 and 10 and W283/285A on daily basis. Point outs are generally late

and handoffs are either late or not done at all because of improper recovery procedures.

This is the 3rd report that has been filed on FACSFAC and these fighter wings who operate

out of [area military bases] on the same exact issues. I have gotten responses as bad as

the military doesn't want to talk about this. Others were to try to talk about a LOA meeting

to address not only the LOA, but the SOP or lack of SOP we have with them. Either way

nothing has changed in past 6 months or longer since my last report. My recommendation

is to negotiate directly with FACSFAC San Diego on a new LOA and bring up and fix all

these problems we continue to have on a day to day basis. The controllers all recognize

this as a very high potential for something bad to happen if we cannot get together and fix

this. The Navy Fighter Wings and FACSFAC need to understand you cannot just expect the

Center sectors to fix the problems anymore. Enough is enough.

Synopsis

Oakland Center Controller reported unsafe airspace problems with a Navy Facility when

military flights enter Oakland Airspace without approval.

ACN: 1422415 (24 of 50)

Time / Day

Date : 201702


Place

Locale Reference.ATC Facility : ZZZ.TRACON



Environment


Aircraft

Reference : X






Flight Plan : IFR



Component

Aircraft Component : Elevator Trim System


Problem : Failed


Person : 1

Reference : 1











Communication Breakdown.Party2 : Maintenance


Person : 2

Reference : 2












Communication Breakdown.Party2 : Maintenance


Events





Result.General : Flight Cancelled / Delayed




Assessments



Narrative: 1

Preflight, taxi, and takeoff roll occurred without incident. Shortly after rotation, the

Captain asked me to check my yoke trim as his had quit working. My yoke trim switch was

also not working. It also appeared that the autopilot trim was not working. We verified

that the trim cutout switches were in the proper position. We leveled at 5000 feet,

manually trimmed the aircraft, and informed Departure that we would need a few minutes

of vectoring to address an issue.

After referring to the QRH, we contacted operations to confer with maintenance to see if a

cycling of the Stabilizer Trim circuit breaker would be appropriate in this emergency

circumstance. Departure referred us to [maintenance] so we sent an ACARs message

asking the same question. We also utilized the Call Me function of the ACARs to speak with

dispatch and [maintenance]. After 5 or so minutes dispatch responded with a frequency

(131.17 I believe) and we attempted to contact dispatch and [maintenance] verbally. We

could hear dispatch but apparently they could not hear us, so we called operations and

were informed that they had dispatch on the phone and then we relayed communications

back and forth from that point in that manner.

We asked again about the possibility of a circuit breaker cycling. We located the breaker in

question and after verifying that it was the correct breaker and getting authorization to

cycle it, we cycled the breaker and the electric stabilizer trim function recovered. By this

point we didn't have enough fuel to continue to [our destination] so we completed the

appropriate approach checklists, had dispatch change the destination back to [the origin

airport] and returned for a normal landing.

We submitted a write up using the Electronic Log Book, maintenance ran an operations

check which showed no issues and a new Maintenance Release Document (MRD) was

issued. The aircraft was redispatched, refueled and we continued on with no further

incidents.

Narrative: 2

No overweight landing was accomplished.

Synopsis

Boeing 737 flight crew reported their electric elevator trim system failed after takeoff.

They ran the checklist and returned to land at departure airport using the manual trim

instead.

ACN: 1422220 (25 of 50)

Time / Day

Date : 201701


Place




Environment



Light : Daylight


Aircraft

Reference : X



Make Model Name : Small Aircraft, Low Wing, 1 Eng, Fixed Gear



Flight Plan : None

Mission : Personal




Component




Person

Reference : 1







Qualification.Flight Crew : Private






Events







Result.Flight Crew : Requested ATC Assistance / Clarification


Assessments



Narrative: 1

En route to ZZZ I saw the float in the Ercoupe header tank sight gauge descending. This

typically means the fuel in the main wing tanks (fed to the header tank by the engine fuel

pump) is exhausted. But with known fuel quantity in the mains, yet the bobber is going

down in the sight gauge, this implies either failure of the engine fuel pump or an

obstruction in the fuel lines from the mains to the header (or the main fuel shut off valve

under the instrument panel on the pilot's side is turned off).

I was getting flight following from [Approach] and immediately advised them of a potential

fuel system anomaly. First, I planned diverting to ZZZ1 where I knew maintenance was

available. But as the bobber continued to descend, I feared imminent fuel exhaustion and

diverted instead to ZZZ2.

On the ground, I called the number given to me by [Approach] to confirm I was safely on

the ground. There was fuel self-service available. Initially, I planned on topping the header

tank to its 6 gallon capacity to provide an hour plus range which would permit the legal

VFR flight to ZZZ3. To my surprise, the header tank accepted barely a gallon of fuel.

Examination of the main tanks revealed an appropriate reduction in the fuel level for the

flight time [our departure airport] to where I first noticed the sight gauge anomaly.

I started up, and the sight gauge was normal. I took off and the indicator rod stayed in

then normal position for the remainder of the flight. So, I concluded there was no issue

with the fuel transfer from the mains to the header tank. Rather, there was an

unexplained (for now) anomaly in the float elevation of the sight gauge rod).

When I get to my final destination of ZZZ4, I will consult with the A&P there, and consider

replacing the float assembly, possibly with a non-cork impervious float.

Beyond that, I will explore the feasibility of adding a fuel pressure sensor to register fuel

pressure at the fuel lines from the main to the header tank. With an instrument panel

gauge it would be possible to verify fuel flow to the header tank. If you have to rely solely

on the position of the crude bobber and sight gauge, it becomes impossible to verify

proper fuel flow, including the actual fuel level in the header tank, without landing and

performing a physical inspection of all tanks, and a top off of fuel in the header tank as I

did at ZZZ2.

Synopsis

An Ercoupe 415 pilot reported that the fuel indicator for the header tank indicated he was

losing fuel.

ACN: 1421585 (26 of 50)

Time / Day

Date : 201701


Place




Environment


Light : Daylight

Aircraft

Reference : X



Make Model Name : B767-300 and 300 ER



Mission : Cargo / Freight



Component

Aircraft Component : Fuel Distribution System



Person

Reference : 1










Events







Assessments



Narrative: 1

Departed with full wing fuel and 4.5k fuel in center tank. Both center pumps were turned

on. At level off at FL340 noticed Fuel Config EICAS message, center fuel was at .2 so

turned pumps off. Noticed Fuel Config Eicas message remained on. Upon examination of

Fuel Panel, noticed that there was 35.5 in left tank, and 39.5 in right tank. Total fuel

indicated correctly for fuel used. It appears all center fuel was consumed by right engine.

We then balanced fuel and flight was normal from that point on. System was written up in

logbook.

Synopsis

A B767-300 pilot reported that center tank fuel was used primarily by the right engine

leaving the amount of fuel in the wing tanks unbalanced.

ACN: 1421162 (27 of 50)

Time / Day

Date : 201701


Place




Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR



Component

Aircraft Component : Fuel Tank



Person : 1

Reference : 1








Person : 2

Reference : 2








Events




Were Passengers Involved In Event : N




Assessments



Narrative: 1

Passing 18,000 on climbout noticed an unexplained decrease in right outer fuel quantity.

Followed QRH procedures for fuel feed manual control and fuel leak. Did not confirm a fuel

leak but right outer quantity continued to decrease. Right outer [fuel quantity] should not

have burned down at all. After completing fuel feed manual control with center pumps off

to ensure fuel was burning from inner tanks right outer continued to decrease. Entered

fuel leak checklist and did not confirm a fuel leak because only indication was an

imbalance but fuel total continued to burn down on pace with flight plan release. Consulted

with [Maintenance] and Airbus tech pilot. Diverted to nearest airport. Aircraft landed

exceeding outer wing tank limits, no problems noted. On the ground with engines

shutdown and no fuel pumps on, right outer continued to decrease quantity over a one

hour period.

Narrative: 2


Synopsis

A300 flight crew reported an unexplained decrease in right outer fuel quantity and

diverted.

ACN: 1420814 (28 of 50)

Time / Day

Date : 201701


Place

Locale Reference.Airport : BWI.Airport

State Reference : MD


Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Tower : BWI


Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR

Mission : Passenger


Airspace.Class B : BWI

Person

Reference : 1










Events







Assessments




Narrative: 1

Upon arrival to BWI the ATIS indicated strong wind gusts and cross winds. We joined the

visual approach to Runway 33L behind a Company aircraft. After receiving landing

clearance we heard the aircraft in front of us call go-around for windshear. We decided to

continue our Approach. Shortly after that, we received a windshear warning and

performed the windshear recovery maneuver. Once we were stable we requested a

runway change to Runway 28. We were vectored to follow Company to 28. At this time our

fuel on board was 5.7. At our [departure airport] the Captain requested an additional 900

pounds of fuel due to the high winds in BWI. We decided that in the event of a second-go

around, we were going to proceed to another airport.

I then gathered the weather in [several suitable alternates]. We were then cleared for the

visual 28. The Company aircraft ahead of us landed successfully. At approximately 600

AGL we once again encountered windshear and executed a go-around. We leveled off at

2000 ft and made the decision to divert [to an alternate] since the weather conditions at

the other airports was similar to BWI. We requested immediate vectors. Our fuel was 5.0.

We planned a burn of 2.5 to [the alternate]. We knew that [several other alternates] were

additional options in the event our burn calculations were incorrect.

We sent Dispatch a message to inform them of our divert plan. The message we received

back was "why? What's up in BWI", not any information on weather or fuel burn or other

options were given. We spoke with the passengers and flight attendants and monitored

our minimum fuel situation. We informed Potomac Departure that we were minimum fuel

and were given direct to [alternate]. We landed successfully. Still Dispatch only planned on

us arriving back to BWI landing with 6.5 in the same weather conditions. We added more

fuel to ensure option for arrival in BWI.

The Captain and Dispatcher are jointly responsible for the safety of a flight. In this

situation Dispatch had minimal situational awareness of not only the weather in BWI, but

also, after we executed a second go-around and informed them of the divert, we were

planned to land with only 5.7 (the Captain added 900 pounds). It is imperative that

Dispatch maintain situational awareness and communicate more effectively to ensure a

safe outcome of a flight.

Synopsis

B737 First Officer reported diverting to an alternate after experiencing windshear on two

consecutive approaches to BWI.

ACN: 1420276 (29 of 50)

Time / Day

Date : 201701


Place




Aircraft

Reference : X


Make Model Name : MD-80 Series (DC-9-80) Undifferentiated or Other Model



Flight Plan : IFR

Mission : Passenger


Person

Reference : 1








Events


Anomaly.Deviation - Procedural : Weight And Balance


Anomaly.Deviation - Procedural : MEL



When Detected : Pre-flight


Assessments




Primary Problem : Procedure

Narrative: 1

We picked up the aircraft with MEL FWD AUX TRANSFER PUMPS BOTH INOP.

I reviewed the MEL and was concerned about fuel loading Takeoff Performance System

(TPS) identifier. I called load control and asked what this meant. After being put on hold

for a while, they explained that this meant that the unrecoverable fuel in the FWD AUX

tank should not be shown or considered as ballast fuel on the TPS and was put into Empty

Operating Weight where it would stay. MEL states 1. Fuel in FWD AUX TANK is unusable.

2. The note explains AFT AUX TANK FUEL may be considered unusable and fuel may be

left in it under certain conditions. We had no AFT AUX TANK FUEL, so I did not think this to

be a problem. In the cockpit, I placed a second call to a load control supervisor about the

Minimum Zero Fuel Weight (MZFW) not being reduced by the amount of fuel in FWD AUX

tank, and he assured me this was proper since the MEL says reduce the actual Zero Fuel

Weight (ZFW) and not the MZFW. However, the MEL placard does call it ballast fuel. This

seemed to be a conflict of MZFW procedure, but since they are the ones to interpret the

MEL, I accepted it.

The next day, the First Officer spoke with another pilot, and the point was brought up that

the aircraft was out of AUX fuel balance. I am not sure this is a problem since the AUX fuel

and balance figure is an Aircraft Flight Manual (AFM) limitation and this condition is MEL

approved. Nothing about the TPS flagged this condition. I called load control twice about

FWD AUX TANK fuel in this configuration including a supervisor, and no one believed the

aircraft was fueled in an improper condition.

The whole premise of this MEL is when the aircraft was previously in flight to have FWD

AUX TANK pumps fail in flight, which means fuel will be in FWD AUX TANK with fuel

exhausted in AFT AUX TANK by landing. This was the condition of the aircraft when I

picked it up. The MEL talks a lot about how to handle the ZFW part of the equation, and I

believe leads you down a path that this fuel loading has been taken into account. I believe

the MEL note that reads some of the fuel in the AFT AUX TANK may require to be

considered unusable is misleading, since by all odds, there will be no fuel in the AFT AUX

TANK at this time, as was in my case. If the AFM LIMITATION still applies in this condition,

I believe the MEL should clearly state that it only applies if there is no more than 400 LBS

of fuel in the FWD AUX TANK. This would make this MEL only apply in a very narrow

circumstance.

Synopsis

MD-80 Captain reported what he feels is a flaw in a company MEL procedure dealing with

Forward Aux Transfer Pumps Inoperative.

ACN: 1420269 (30 of 50)

Time / Day

Date : 201701


Place




Environment


Light : Night

Aircraft

Reference : X



Make Model Name : Regional Jet 700 ER/LR (CRJ700)



Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Turbine Engine



Person : 1

Reference : 1









Person : 2

Reference : 2








Events


Anomaly.Flight Deck / Cabin / Aircraft Event : Smoke / Fire / Fumes / Odor




Result.General : Evacuated



Assessments



Narrative: 1

Emergency landing (CA landing), after my visual approach, due to R ENG FIRE. At FL220, I

(FO, Pilot Flying) identified apparent excessive fuel flow, a significant fuel flow differential,

and continuous R AUTO FUEL CROSSFLOW status message shortly before being cleared to

descend. CA then also noted the oil and fuel temps had significant differences from side to

side. We briefly monitored fuel condition and engine indications, and the CA determined

we did indeed have a fuel issue - fuel had rapidly decreased to below planned reserve fuel.

We requested a straight-in approach due to potential fuel problem, and subsequently

received vectors and descent.

We completed the In-Range checklist, above and below the line, by approximately 9000

MSL. Then received R ENG FIRE warning approximately 7000 MSL, all indications had

remained green until this point. CA ran the checklist for ENG FIRE In-Flight, [advised ATC]

and notified flight attendants, while I continued to fly and talk to ATC as needed. The R

ENG FIRE warning persisted after completing all steps of the ENG FIRE In-Flight checklist.

We received clearance for a visual approach. I maintained 250 knots until we had to slow

for landing configuration, we landed with Flaps 20. CA took the flight controls at 2500 MSL

and approximately 6 miles from the runway. He safely landed the plane and we evacuated

the aircraft on [the] runway, completing Passenger Evacuation checklist. Airport fire crew

confirmed right engine fire and extinguished with foam. We accounted for all passengers

and flight crew, there were no injuries reported from either. CA notified Dispatcher,

Maintenance Control, and the Chief Pilot. Passengers and flight attendants were

transported to the terminal via three airport buses. CA and I provided written statements

to [appropriate personnel].

Once the aircraft was cleared for movement, operations/ramp personnel towed aircraft to

the ramp, with the CA and I riding brakes. Operations and ground crews inventoried and

removed passenger belongings from aircraft cabin, baggage was also removed from cargo

compartments, and returned to terminal for passengers to claim.

Narrative: 2

During gradual descent into [destination] the FO (pilot flying) brought to my attention the

fuel auto transfer was operating for an unusually long time. We then determined the right

engine appeared to be consuming more fuel than the left. After recalculating, we realized

the fuel situation was serious enough to advise approach we were in a minimum fuel

situation. ATC issued a direct route to the airport and I requested a different runway to

save time. While I was considering options to conserve fuel the fire bell sounded and a

right engine fire warning message appeared. We executed the emergency procedures

checklist items and shut down the engine but were not able to extinguish the fire. We

[advised ATC] and landed where firefighters extinguished the fire. A passenger evacuation

was conducted on the runway using the main cabin door. There were no injuries. The

cause of the fire is not yet known.

Synopsis

CRJ-700 flight crew reported shutting down the engine inflight and evacuating on the

runway after receiving an engine fire warning during the approach.

ACN: 1419897 (31 of 50)

Time / Day

Date : 201701


Place

Locale Reference.Airport : DCA.Airport

State Reference : DC


Environment


Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : DCA





Flight Plan : IFR




Route In Use.STAR : FRDMM3

Airspace.Class B : DCA

Person

Reference : 1












Events

Anomaly.Deviation - Altitude : Excursion From Assigned Altitude


Anomaly.Deviation - Procedural : Clearance


Anomaly.Inflight Event / Encounter : CFTT / CFIT



Result.Flight Crew : Returned To Clearance


Assessments

Contributing Factors / Situations : Environment - Non Weather Related



Narrative: 1

On the River Visual 19 to DCA we were issued a "low altitude alert" by Reagan Tower. We

were approximately 4 DME DCA at approximately 1,000 feet. The Captain immediately

leveled off until we joined a 3:1 glide path and landed without incident.

After thoroughly debriefing the event, it was determined that two issues contributed to the

low altitude:

While on the FRDMM 3 RNAV arrival, we were issued an unanticipated hold at PLDGE

intersection. After 30 minutes of holding, we were cleared inbound and, almost

immediately, were issued a 90 degree vector off course. We declared "minimum fuel".

When we joined the arrival, the FMGC showed us landing with 50 minutes of fuel. The

additional discussion about our fuel state distracted us both from focusing exclusively on

the approach.

It was the first time that either of us had flown the River Visual approach in some time.

The approach was conducted at nighttime. Due to these factors, the majority of our time

was spent "outside the aircraft" so as to avoid the prohibited area and locate Runway 19.

This extra "outside" time reduced our altitude awareness.

Synopsis

A319 First Officer reported receiving a low altitude alert from ATC on a night visual

approach to DCA.

ACN: 1419576 (32 of 50)

Time / Day

Date : 201701


Place




Environment



Light : Daylight


Aircraft

Reference : X


Aircraft Operator : FBO

Make Model Name : Skyhawk 172/Cutlass 172



Flight Plan : VFR

Mission : Training


Component



Problem : Failed

Person

Reference : 1















Events





Result.Flight Crew : Rejected Takeoff

Result.Flight Crew : Returned To Gate

Assessments




Narrative: 1

During a "long cross country" training flight to meet the experience requirements for a

Private Pilot Certificate an engine failure occurred at the moment of rotation. The takeoff

was aborted and the aircraft was safely taxied off the runway using remaining energy.

After examination of the aircraft a large amount of water was removed from the

gascolator. Both fuel tank sumps produced no water at all.

The aircraft was inspected by the student pilot who claimed that fuel samples were taken

from both wing tanks and the gascolator. The student had around 60 hours of flight time

at the time of the incident, and the instructor was obtaining a weather briefing and filing a

flight plan during the student's preflight. The instructors actions during preflight was to

examine fuel quantity, oil quantity, drain the gascolator for a period of 2 seconds (without

taking a sample) and perform a general walk-around of the aircraft inspecting for obvious

damage and [irregularities]. Taxi and run-up were normal with no signs of engine

problems prior to take-off.

The previous 4 weeks it has been raining unusually in the area. The incident aircraft had

been parked in a steeply inclined parking space (nose down) for the previous 4 days

without being flown. 2 weeks prior to this incident the instructor was conducting an initial

flight lesson for a new student in a 152. While sumping the gascolator the sample did not

have the blue color of 100LL fuel, and the fuel smell was slightly less than usual. It was

only after a very careful inspection which lasted more than 20 seconds (and by sumping

an additional sample from a known-good fuel tank) that it was determined the sample cup

initially contained only water. Because of this, fuel contamination was discussed in detail

(including pictures of the sample) during the staff's monthly safety meeting a few days

before this incident. While initially it was determined that the student pilot and instructor

failed to notice the water contamination and the lack of blue dye in the sample cup, hours

later it was realized that the samples were taken while the aircraft was parked nose-down

on a steep incline. It is highly possible that the water was located in the forward portion of

the fuel tanks and did not enter the fuel system until the aircraft was moved to level

ground.

Due to this incident, as an instructor I will no longer be using the "timed" method of

draining the gascolator which is a common practice and will instead ensure that an actual

sample is taken with the sample cup from all three drain points. Additionally, close

supervision of even "experienced" student pilots will be performed, as well as other safety

improvements during preflight inspection to prevent a similar incident from occurring in

the future. Finally, additional scrutiny will be paid to aircraft using the parking spaces in

question while sumping fuel. These spaces are not popular and are only used when

required, as the incline mandates a minimum of 2 people for push-back, with three people

preferred.

Synopsis

C172 instructor pilot reported experiencing engine failure on the takeoff roll that was later

traced to water in the fuel.

ACN: 1419551 (33 of 50)

Time / Day

Date : 201701


Place




Environment

Weather Elements / Visibility : Rain

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Ground : ZZZ


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



Flight Plan : IFR

Mission : Passenger


Person : 1

Reference : 1




Function.Flight Attendant : Flight Attendant (On Duty)



Person : 2

Reference : 2




Function.Flight Attendant : Flight Attendant In Charge



Events





When Detected : Aircraft In Service At Gate

Result.General : Flight Cancelled / Delayed


Assessments

Contributing Factors / Situations : Airport




Narrative: 1

We started our day with a flight to the west coast. As we got closer the CA called and

notified us that we are short on fuel and can't continue because of the weather conditions

and that we will be diverting to ZZZ to get some fuel. He also notified the passengers after

we got off the phone with him. We then prepared the cabin for arrival. Everyone seemed

okay with it. We landed in ZZZ and had to sit on the ground waiting on a gate. After an

hour or so of waiting for the gate they decided to bring the fuel truck to us instead. With

the fuel truck came the fire department to make sure everything went smoothly. In the

meantime Flight attendant A and I talked to the passengers answering all the questions

they had for us. During the wait the CA made sure to let the passengers know what was

going on as often as possible as we did as well. Soon after we got fuel we were hoping for

a takeoff but we got another delay because of the weather in ZZZ1. He let the passengers

know that they are welcome to get up stretch use the lavatories as Flight Attendant A and

I passed out snacks and drinks. A couple in First class wanted to get off the plane if we

had a further delay. Also a lady in the back had her final destination as ZZZ so she wanted

to get off the plane as well. We let the CA know and that there were a few passenger who

wanted to get off. As time passed by another lady in first class wanted to get off because

she looked up flights and saw that she can take a flight out to her final destination from

ZZZ instead. We notified the CA about that as well.

At this point we had been sitting on the ground over 2 hours, that's when the CA called us

and told us we had a gate open to use and wanted to know if the cabin was secure to taxi.

We secured the cabin and took our seats and called him back to let him now we were all

good to go. We taxied for a minute then we came to another stop. I'm not sure what

happened but we lost our gate. CA made an announcement saying we don't have a gate

anymore, but they are working on a solution and he will notify everyone as soon as he

gets some more information. After a while the CA called us and told us to pull the slide at

the main cabin door, then he said hold on a second I'm going to double check that's what

they want us to do and call us back. A few moments after he called and confirmed that

that's what he wanted us to do. That's when Flight Attendant A opened the door and

pulled the slide open and put the safety rope across the door. After that the passengers

were confused and questioning the slide. Moments after the police, firetrucks and

paramedics and the stairs as well as ground crew and company personnel were all

surrounding the plane. The CA came out and made a PA explaining to the passenger on

what was going on and that we will be deplaning from the back of the plane. I was

instructed to open the L2 door so the stair can pull up and he passengers can get off. After

I opened the door and put the safety rope on the door we sat waiting on the shuttles to

get there to take the passengers. The fireman were there to help passenger deplane safely

as it was raining. After everyone deplaned the crew stayed on the plane as the CA took

care of more stuff on the phone about an hour after we got off the plane and headed to

our hotel.

Narrative: 2


Synopsis

Flight Attendants reported diverting due to fuel issues. The flight had difficulty getting a

gate and after a long period of time the Captain ordered a single slide to be deployed. Air

stairs were used to deplane the passengers.

ACN: 1419034 (34 of 50)

Time / Day

Date : 201701


Place



Relative Position.Distance.Nautical Miles : 5


Environment


Weather Elements / Visibility.Visibility : 0.5

Light : Daylight


Aircraft

Reference : X



Make Model Name : B737 Next Generation Undifferentiated



Flight Plan : IFR

Mission : Passenger




Person : 1

Reference : 1










Person : 2

Reference : 2









Events

Anomaly.Flight Deck / Cabin / Aircraft Event : Other / Unknown

Anomaly.Deviation - Speed : All Types





Assessments



Narrative: 1

It was the last leg of a 6-day sequence (2 to 3 days trips) for me; last leg of a 3-day

reserve block for my First Officer (FO). All (but one) flights were flown on NG aircraft. We

deiced during our originator flight (first leg). Then (second leg) I tried to coordinate some

weight issues with the Dispatcher and Ops Agent, related to: freight, dead headers, and

the fact that [there] was only [one] qualified alternate around ZZZ, due to low visibility in

the area.

During the Cruise portion of the flight we discussed and planned for any approach in ZZZ,

alternate courses of action as well as establishing our Bingo fuel. As we approached ZZZ it

was evident (by listening on the radios and monitoring our TCAS information, as well as

the ATC Controllers voice) that ZZZ was extremely busy. In over a decade flying in and

out of ZZZ I don't recall it been so busy. ZZZ was using both Runway XY. We were

assigned XYR. Visibility (SM) was below minimums but RVR was good. I flew the ILS XYR,

which ended in a missed approach.

The go-around went well, but we got distracted with a "Using Reserve Fuel" message and

started to discuss options. We were given an easterly heading and leveled off at 3000 feet

MSL. After reducing power and crosschecking my ADI, I engaged the Auto Pilot (AP) and

went back to look at the weather information on the FO's MCDU. As I quickly returned to

crosscheck my instruments, I saw the airspeed decreasing through 180 knots and almost

simultaneously (with the corner of my eye) I saw a blinking BUFFET ALERT message (no

other indications).

I immediately added power, quickly returning to the assigned speed (210). I then realized

that during my attempt to silence the AP Disconnect Warning horn I inadvertently

disconnected the Auto Throttle (out of "old" habit patterns). I reengaged the AT and

verified appropriate FMA indications. The remainder of the flight was uneventful, as we

landed on XYL after flying the second ILS, all the way down to minimums.

Maybe consider having the Pilots practice several go-arounds by the use of the Take Off

Go Around (TOGA) buttons only (i.e. reduced/full AT). I fully support our efforts and

transition to [company SOP]. It works!! Last, but not least, this goes to prove that things

like these can happen to the best of us, in spite of our best efforts, training, and planning.

For me (and anyone who would listen); this is my reminder....Stay with the BASICS:

(1)(Aviate, Navigate, Communicate); (2) Hack the clock or count backwards before

rushing, there was no need to discuss actions until we established ourselves on downwind;

and (3) in spite of best advances in technology/automation the laws of aerodynamics still

make the aircraft fly.

Narrative: 2


Synopsis

B737NG flight crew reported disconnecting the autothrottles and aircraft slowing to

BUFFET ALERT message airspeed after missed approach.

ACN: 1418563 (35 of 50)

Time / Day

Date : 201701


Place

Locale Reference.Airport : SFO.Airport



Environment

Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZOA





Flight Plan : IFR

Mission : Passenger



Route In Use.STAR : SERFR2

Airspace.Class A : ZOA

Person

Reference : 1








Human Factors : Other / Unknown

Events








Assessments

Contributing Factors / Situations : Airport


Primary Problem : Airport

Narrative: 1

Flight was dispatched to SFO with required amount of fuel on board. An alternate was not

listed on the release because weather conditions met the "1-2-3" rule and was not

required.

Approximately 30 miles prior to intercepting the SERFR waypoint on the SERFR2 arrival

into SFO ATC gave us direct to NRRLI, shortly after we received this and complied with the

clearance ATC advised us that they had holding instructions and asked if we were ready to

copy. They instructed us to hold at SERFR as published at FL300 with leg and speed

lengths at our discretion and gave us an Expect Further Clearance (EFC) time of XB15Z

with current time of XA30Z.

After programming the hold we started to calculate our Burn Alternate Reserve (BAR) fuel.

We had 800 LBS required from SERFR to runway, 500 LBS for the missed, and 2450 LBS

for our reserve. We determined that our minimum fuel for before needing to leave the hold

was 3750 LBS.

I text dispatch with our hold location, Fuel On Board (FOB), and EFC time and didn't hear

anything back in what I thought was a timely manner, so I decided to call on ARINC to

find out what BAR number they had determined.

FOB at this point was 4700 LBS and we were burning about 2400 LBS per hour at QRH

hold speed of 207 KTS and determined that we could only hold until XB00z and not the

EFC of XB15Z. We relayed this to ATC and they asked what our alternate was. I told them

we didn't have one but that I would talk to company and determine one.

When communication was established, the dispatcher sent only the top part of the

computer flight plan to our ACARS which was difficult to read. He then sent it to our

printer but it was difficult for me to determine what BAR number that they had determined

because they had not used the BAR method that we had been taught in training.

I saw that they had added in OAK as the alternate and that it would take 850 LBS to get

there. I subbed the 850 into the BAR equation in place of the missed and came up with

new number of 4100 LBS, I amended the release and asked ATC if we were going to get a

relief on the EFC time to which they replied that it probably wouldn't happen.

At this point we were at 4200 LBS FOB and I told them that our alternate was OAK and

that we needed to go there now and I declared to them that we were at Minimum Fuel.

They cleared us direct to OAK and then direct EMZOH and the EMZOH3 arrival. As we

approached EMZOH ATC started to descend us for the arrival when dispatch sent a

message to change the alternate to SJC. I responded and told them unable due to our

fuel.

I put SJC into the fix info page and it showed a bearing of 104 degrees and 42 miles. We

were currently on a north easterly heading and I made the decision that I did not to turn

around to go to SJC if they were landing north when I could go straight to OAK landing

north.

We touched down at OAK with 2700 LBS on the fuel quantity gauge. We had several

passengers wanting to deplane in OAK and I conferred with an on duty chief pilot about

what to do. Most of the passengers that had carry-on luggage decided to deplane and I

spoke with the chief pilot and gate agent. We added fuel and re-dispatched to SFO without

further complications.

The only suggestion that [I] could say is that SFO is an airport that experiences large

delays because the airport does not have the capacity to support the amount of aircraft

arriving and departing when they experience anything other than VFR conditions and that

skews our new historical fuel reference numbers used in fuel planning and could cause

further potential diversions downline because of unrealistic holds placed on us by ATC

because we simply do not have to extra fuel to meet ATC's requirements.

Synopsis

Air Carrier Captain was put into holding unexpectedly and determined the aircraft didn't

have sufficient reserve fuel for the Expect Further Clearance time given. No alternate

airport was included on the flight plan so Dispatch amended the flight plan and they

diverted to an alternate.

ACN: 1417403 (36 of 50)

Time / Day

Date : 201701


Place

Locale Reference.ATC Facility : ZAB.ARTCC

State Reference : NM

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZAB


Make Model Name : Medium Transport, High Wing, 2 Turboprop Eng



Flight Plan : IFR

Mission : Passenger


Airspace.Class A : ZAB

Person

Reference : 1








Events






Assessments



Primary Problem : Company Policy

Narrative: 1

We took off to PHX with the normal burn fuel for the flight and only the standard 700 lbs

of contingency fuel. The forecast for the time was high ceilings and good visibility. About a

little more than half way, Center tells us that we should slow down and expect holding

instructions. We slowed down and received holding instructions at GEELA with an EFC time

of 30 min from our present time. I texted dispatch the situation including the way point,

FOB, and atltitude. I then started looking for alternates. The closest airport I could find

that was in the system was TUS and we would only be able to make it if we proceeded

directly there at that time. At this point we were only 500 lbs above min fuel. Dispatch

then got back to us and told us they were in communication with ATC on the phone and

instructed us to declare min fuel. We declared min fuel and did another turn in holding. At

this point we had committed to landing at PHX. We then received radar vectors to PHX and

landed at min fuel.

Synopsis

Passenger turbojet flight reported of an unexpected holding for the destination resulting in

landing with minimum fuel.

ACN: 1417212 (37 of 50)

Time / Day

Date : 201701


Place

Locale Reference.Airport : ZZZZ.Airport

State Reference : FO


Environment


Aircraft

Reference : X





Flight Plan : IFR

Flight Phase : Descent

Component




Person

Reference : 1











Events








Assessments



Narrative: 1

Fuel imbalance, possible fuel leak. Followed all SOPs. Informed ATC of aircraft condition

and requested emergency equipment. Uneventful landing and gate arrival. Fully debriefed

with crew, dispatch, Duty Manager and Maintenance Control.

Synopsis

B777 Captain reported of a fuel imbalance which was caused by a possible fuel leak or

malfunctioning fuel gauge. ATC was advised and a normal landing ensues.

ACN: 1416985 (38 of 50)

Time / Day

Date : 201701

Place



Environment


Aircraft

Reference : X





Flight Plan : IFR

Mission : Cargo / Freight




Person

Reference : 1








Human Factors : Human-Machine Interface

Events










Assessments




Narrative: 1

Normal operations until 5 hours into flight.

We operated in "econ" which showed greater fuel and still an on time arrival, and very

near flight planned M.84. We operated and climb near as the flight plan indicated, and we

held steady at 200 to 400 LBS ahead on fuel, and 200 to 500 LBS under burn, again until

5 hours into flight.

At crew change we first went to 600 LBS behind from 200 LBS ahead and to 600 LBS over

burn from 300 LBS under burn. We received ATC clearance to cruise M.83 for the crossing

as this was close to "econ" and indicated about 1,200 LBS better fuel at landing. Tailwind

had drop about 20 KTS from flight plan.

Fuel flows where averaging under the flight plan. The burn and fuel was noted to relief

crew. Upon return from rest increased over burn was noted to me at 140W as 2,100 LBS

and behind 2,000 LBS gross. Inflight highest over noted as 2,600 LBS if memory serves.

We noted a 6,000 LBS over burn after landing, but I failed to check number carefully as

we subtracted planned flight burn from the total burn (not the flight burn), the over burn

was 1,386 LBS when subtracting the flight planned fuel burn from the actual flight burn,

there was 2,900 LBS taxi out burn, and 2,000 LBS taxi in burn. We took off 5,000 LBS

under flight plan weight, so I do find it strange that we burned extra fuel; we were able to

save another 1,000 LBS as ATC cleared us direct to fix on the approach deleting the arrival

and we did a constant descent saving that 1,000 LBS, which if added to the 1,386 LBS =

2,300 LBS very close to the highest over burn calculated in cruise near the end of the

flight. There are good notes on the master flight plan to be utilized in the investigation. I

have noticed that the burn and fuel does well and then starts slowly over burn about half

way into flight, winds aloft and ground speed difference and temperature. Difference don't

seem to explain this change half way into flight. We did request a reweigh of the cargo.

Normal operation approach, landing, taxi in, shutdown and post flight.

The crew and I wonder about cargo over weight, as there has been some cases of this in

past, and perhaps fuel bias problems. Our error in calculating the over burn once on the

ground was not helpful as well to the most accurate information, but I've corrected that

calculation in the report and other will look at this as well.

Continue to look into the cargo weight and fuel bias, thanks for your time and effort. I

attached some pics of the master flight plan, not best quality, but may help in short term.

Synopsis

Boeing 777 Captain reported a discrepancy in the FMC fuel remaining estimate. Initially it

showed they would be landing with extra fuel, then 5 hours into the flight it showed they

would be landing with less fuel than planned. It may have been due to an un-forecasted

wind shift.

ACN: 1416597 (39 of 50)

Time / Day

Date : 201701


Place



Environment

Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 900 (CRJ900)



Flight Plan : IFR

Mission : Passenger


Flight Phase : Descent


Person

Reference : 1








Events









Assessments




Primary Problem : Company Policy

Narrative: 1

We were dispatched with a planned arrival fuel of 3225 lbs. 2194 lbs was our planned

reserve fuel, and a minimum tanker figure of 1031 lbs was included. Weather was forecast

and observed VMC and an alternate was not required. We flew economy speeds for the

entire flight. As we descended on the arrival, we were told that ZZZ had unexpectedly

gone into holding. An expected time approximately 30 minutes in the future was given. I

calculated the fuel burn and, at our holding speed, we only had enough fuel to hold for

approximately 15 minutes, equating to about two turns. We queried ATC as to the reason

for the hold and he didn't specify other than to say "they just called us on the phone" and

that it was most likely due to volume into ZZZ, as the weather was completely fine

(overcast at 11,000 to the best of my recollection). I kept calculating the fuel and was

growing increasingly concerned.

As we turned downwind on our second turn in the hold, I queried ATC how much longer it

would be; we had to divert right away if we couldn't get into ZZZ. Holding for five more

minutes past this point showed us landing at ZZZ with 2500 lbs., 300 over reserve. They

cleared us out of the hold back to ZZZ. We immediately declared min fuel and they

informed us it would be about a 12 mile final to the runway, which gave us a bit more

margin than forecast. We descended via the arrival. We encountered unforecasted clouds

that required us to activate wing and cowl anti-ice, further increasing fuel burn. We were

also slowed on the downwind leg to 160 knots, forcing us to drastically increase drag and,

thus, fuel burn. Additionally, our downwind was extended a bit. We touched down in ZZZ

at 1900 lbs of fuel, approximately 300 lbs into our reserve.

I continue to believe that our reserve fuel figures are completely insufficient, and that

takeoff fuel calculations, while possibly fitting a definition of "legal," are absolutely

unrealistic. There is no way we can account for a go-around and have 45 minutes of extra

fuel remaining, even with our tanker fuel. I spoke to our dispatcher after landing, who told

us that she is not allowed to put extra fuel in hold for "anticipated" holding. She can only

put it in if she knows ZZZ will go into holding. Neither the dispatcher nor I had any

indication at all that ZZZ would go into holding that day, as the weather was forecast to be

close to ideal, and the flight plan was completed approximately 2.5-3 hours prior to this

event. We unexpectedly had to burn 600 extra pounds, plus the hold, on our way into ZZZ

that day.

In the future, when landing with "normal" loads into airfields where we are planned to

arrive with min tanker plus reserve, and holding instructions are given, I will carefully

consider an immediate divert. I do not feel that this is a proper way, however, to conduct

fuel planning, and I believe the fuel policy should ultimately be revisited carefully with the

input of current line pilots and line check airmen.

Synopsis

CRJ-900 Captain declared minimum fuel after unexpected holding on descent to their

destination. The Captain attributed fuel issues to unrealistic company fuel reserve policies.

ACN: 1415563 (40 of 50)

Time / Day

Date : 201612


Place

Locale Reference.Airport : H19.Airport

State Reference : MO

Environment


Light : Daylight

Aircraft

Reference : X

ATC / Advisory.Center : ZKC


Make Model Name : Baron 58/58TC



Flight Plan : IFR

Mission : Personal



Person

Reference : 1














Analyst Callback : Attempted

Events









Assessments


Contributing Factors / Situations : ATC Equipment / Nav Facility / Buildings

Primary Problem : ATC Equipment / Nav Facility / Buildings

Narrative: 1

Received two DUATS briefs for a flight (two legs with a fuel stop at H19). Briefings

received for flight departing at XA00Z and arriving H19 at XD30Z. On arrival at H19

discovered the entire airfield was completely glazed over in thick ice. Diverted to alternate

airport UIN only to discover that airport also completely glazed over in thick ice. ATC was

unaware of any of the field closures and made recommendation to divert to IRK that I

later confirmed was also glazed over and closed. Another pilot on frequency noted that SPI

had one runway open. Flight concluded safely with landing at SPI. Flight would not have

concluded safely due to fuel starvation had the flight continued on to IRK only to find that

airfield and all others in the area were similarly closed due to ice.

Review of the DUATS briefings confirmed that there were no NOTAMS for either H19 or

UIN indicating the runways or airports were closed. In fact very few of the airports within

about 100 nm of H19 had any NOTAMs indicating runways or airfields were closed. One

exception was MBY that just noted the field closed but offering no reason for the closure.

The widespread storm that was responsible had come through the previous [2 days]. So it

was at least 48 hours later and still no indication in the "official" DUATS briefings of any of

the hazardous conditions over a widespread area. Even Kansas City Center was unaware

of the extent of the problem offering vectors to an airfield whose condition was unsafe.

The "official" DUATS briefing is supposed to provide the pilot with all the information

necessary to make safety of flight decisions. However in this case, DUATS and the FAA

NOTAM system were sorely lacking in communicating the hazardous conditions,

widespread area, or even providing timely information. The safe outcome of this flight was

put at unnecessary risk as a direct result.

Synopsis

BE58 pilot reported that no NOTAMs had been issued for several airports that were closed

due to runway conditions. ATC was also unaware of the closures.

ACN: 1415378 (41 of 50)

Time / Day

Date : 201701


Place




Environment


Aircraft

Reference : X






Flight Plan : IFR



Component : 1

Aircraft Component : Fuel Booster Pump



Component : 2




Person

Reference : 1









Events










Assessments



Narrative: 1

Departed 1.5 hours after scheduled, due to delays associated with winter operations and

ATC traffic flow. On climb out, passing 15,000 feet, field configuration light illuminates, in

conjunction with a 2,200 lb fuel imbalance. The same scenario occurred on the previous

leg, around the same altitude.

In compliance with the QRH, turned on cross feed pumps to balance the fuel. Immediately

upon configuring the aircraft for cross feed, the Master Warning light and associated EICAS

notifications illuminate. Over the next 20 minutes, the EICAS messages and warning lights

illuminate intermittently, and the fuel quantity gauges sequentially fail. The left quantity

gauge indicates a fuel loss of nearly 14,000 lbs (16,000 to 2,200 lbs), fails, and then

resumes indicating with inaccurate quantities. The totalizer also fails or reports inaccurate

quantities.

We accomplish the QRH procedure for a suspected "fuel leak" which directs us to not

accomplish the cross feed procedure. We also coordinate with the Flight Attendants (FA) to

visually check to see if they can detect fuel possibly leaking from the wings as contrails.

They verify that they do not see any fuel leaking.

We immediately contact dispatch and Maintenance via SATCOM to discuss the situation

and possible resolutions. We indicate that we're fairly certain that it is probably an

indicator problem. However considering the the operational and weather situations in

Newark, we are uncomfortable taking a plane with known malfunctions into a degraded

airport, when we have viable stations to divert to with adequate support. After

coordinating with Dispatch, Maintenance Control and the Duty Manager, we concur that we

will divert into ZZZ.

We execute the divert in accordance with Flight Manual procedures, and land without

incident.

Synopsis

B757 Captain reported a fuel quantity gauge and fuel pump anomalies during climb out

and elected to divert to a suitable alternate for maintenance.

ACN: 1415219 (42 of 50)

Time / Day

Date : 201701


Place



Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger



Component

Aircraft Component : Indicating and Warning - Fuel System



Person : 1

Reference : 1








Person : 2

Reference : 2









Events






Assessments



Narrative: 1

Possible fuel leak, below minimum required fuel indicating, while several hundred miles

out over ocean with no place to land nearby. First declared minimum fuel, [we were]

considering a diversion [to a closer alternate] instead of [continuing to] destination. With

unknown quantity and declining indications, advise a fuel emergency. [We were] able to

land [at destination]. Still not sure of actual quantity after landing, but suspected

erroneous indications due to previous problem a week earlier [on] this plane. All was done

with concurrence [of] Dispatcher and Maintenance Control.

Previous similar problem was incurred with this aircraft, and probable repair attempt left

problem remaining. Previous problem also came upon return from [a European station], so

additional concern was possible water in fuel there.

Narrative: 2

This was a trans-Atlantic flight that experienced a fuel indication issue. About 90 minutes

prior to our re-dispatch point we requested and received a re-dispatch from our

dispatcher. Our fuel log throughout the entire Atlantic crossing was on target. About ten

minutes prior to the re-dispatch point we noticed that the number two main fuel tank

indications began fluctuating by as much as 2-3 thousand pounds. This same situation had

been documented a week earlier in the Aircraft Maintenance Log (AML). This difference in

fuel would adversely affect our planned re-dispatch fuel requirement. The Captain used the

SATCOM to talk directly with our dispatcher, who was able to adjust our re-dispatch

requirements to accommodate the situation, allowing us to continue [to] our destination.

The Captain also brought Maintenance Control into the discussion for their input and

assistance. The Captain and dispatcher agreed that it would be prudent to request

"minimum fuel priority" from ATC as a precaution at that time.

We continued to monitor and crosscheck our fuel burn as we approached our coast in

point. Approximately one hour from [destination] and still over-water, we initiated a

preliminary descent to twenty thousand feet. At this point the FMC gave fluctuating and

conflicting indications that we would now land three to four thousand pounds below our

legal arrival fuel limit. The Captain again conferred with Dispatch and they ultimately

decided that given our circumstances and current position that it would be best to continue

straight-in to [destination]. It was decided that because of the questionable fuel

indications we would advise of an emergency due to the fuel issue.

We received vectors straight to the airport and an uneventful approach and landing was

made. After landing our indicated fuel was 15,100 pounds, well within our tolerances for a

legal arrival. A detailed AML entry was made to assist maintenance with trouble-shooting

this fuel indication issue.

It appears that the fuel indication anomaly that we experienced was very similar to an

event that was documented in the AML of this aircraft a few days prior.

Synopsis

A330 flight crew reported experiencing a fuel quantity anomaly on a trans-Atlantic flight

that indicated a possible fuel leak. The flight was able to safely continue to destination.

ACN: 1414688 (43 of 50)

Time / Day

Date : 201605


Place



Environment

Weather Elements / Visibility : Thunderstorm



Light : Daylight

Aircraft

Reference : X



Make Model Name : Regional Jet 700 ER/LR (CRJ700)



Flight Plan : IFR

Mission : Passenger



Airspace.Class C : ZZZ

Person

Reference : 1









Events

Anomaly.Ground Event / Encounter : Ground Strike - Aircraft







Assessments




Narrative: 1

An unforecast thunderstorm left us making decisions with less fuel than we often would

have had in this situation. Had we more fuel, holding and waiting for the weather to pass

and knowing we could still divert if it didn't would have been ideal. That is not the situation

in which we found ourselves. We had enough fuel for one approach, a missed, and a

diversion. I feel that under the circumstances, our decision making was appropriate. Our

timing was unfortunate. Gusty, shifting, changeable winds in the flare are an extreme

hazard. By the time its extent was apparent, we were well past the point at which a go

around would have been safe or even probably successful.

There was no alternate, as current and forecast conditions at our time of departure were

excellent. The fuel planning was adequate for the expected conditions. The TAF was

XX:00Z/XX:24Z 04003KT P6SM VCSH FEW035 BKN110 VRB02KT 5SM BR OVC035

36009KT P6SM VCSH OVC018 36008KT P6SM OVC050. The METAR was VRB06KT 10SM

SCT033 BKN055 BKN090 BKN250 18/12 A2999 RMK AO2 RAB37E49 SLP152 P0000

T01780117. The flight was routine and uneventful until we spotted lightning while inbound

to ZZZ on the ZZZZZ Intersection. We immediately turned on the radar and requested

Terminal Weather Information for Pilots (TWIP) and a new ATIS, revealing several cells

northwest of ZZZ and moving towards the airport. The ATIS still showed calm winds at the

surface.

While the First Officer (FO) continued to analyze the TWIPs and the radar images, I

assessed our fuel situation, including ability to hold and/or divert, and seated the flight

attendants with the advice that it may be rough ahead. As no alternate was planned, our

fuel situation would not allow for holding long enough to be confident that the weather

would have passed ZZZ. It may have, it may not have - that is unacceptable planning,

putting a hold and wait for the weather beyond the acceptable risk threshold. I determined

that the weather in ZZZ1 was acceptable, and that an approach into ZZZ, a missed, and

the necessary diversion around the weather (which was between us and our impromptu

planned diversion airport) was possible, though we would arrive in ZZZ1 with min fuel.

As we continued inbound to ZZZ on the ZZZZZ Intersection, the storms also continued

their advance. I queried approach about the surface winds, and finding them insignificant

(well less than 10 knots,) requested landing on runway XY instead, thus saving us the

requisite time to fly a downwind and getting us on the ground with a greater distance

between us and the oncoming weather. The request was denied due to traffic

considerations. The FO and I briefed the new plan, leaving tacit a review of the potential

go around, as we've briefed it frequently in the recent past.

We continued inbound, now via vectors. We remained in VFR conditions throughout. We

called the field in sight approximately abeam it, and were cleared for the approach with

instructions to follow the preceding aircraft. As anticipated, the FO kept the speed up until

the base turn. We were busy configuring and turning and triple checking everything. On

the base turn, we began to experience light turbulence. The tower controller gave us an

imprecise wind update, something along the lines of feeling the wind increase. I had to ask

him to say again due to workload. We turned approximately a 3 mile final with the storm

approximately 6 miles from the field. The FO rolled out right on localizer and glideslope.

We were cleared to land with all checklists complete and increasing turbulence, plus and

minus 5 knots.

The FO flew it well, maintaining pitch and airspeed admirably under the circumstances,

and I added occasional advice about power settings and speed maintenance due to the

challenging conditions and my strong interest in making sure that he continued to fly it

well. I followed him on the controls in case I needed to take them at any point, but at no

point did I take the controls or did he think that I had. We were alert to the possibility of

and ready for a wind shear caution or warning, but there was none. As he entered the

flare, a sustained gust pushed us a bit high and elongated the flare. As the aircraft slowed

and the ailerons became less effective, greater control movements were made to maintain

control. Quickly shifting winds as the aircraft slowed induced a right roll and contact

between the surface and right wingtip just before touchdown.

We landed at approximately 69,000 LBS with 3,700 LBS of fuel on board, almost exactly

what the flight was planned to land with. We were advised that on landing, the storm was

approximately 4 miles from the field.

The flight attendants and passengers were unaware of the ground contact.

I know weight and fuel savings are an important consideration when running an airline,

but a slightly greater fuel buffer might offer pilots more options, particularly as we head

into the summer months when storms, including the unforecast variety, will be more

frequent.

Synopsis

CRJ-700 Captain reported striking the runway with a wingtip on landing flare in shifting

wind conditions.

ACN: 1414140 (44 of 50)

Time / Day

Date : 201701


Place




Environment


Light : Daylight

Aircraft

Reference : X


Make Model Name : Cessna Citation Sovereign (C680)



Flight Plan : IFR



Component

Aircraft Component : Engine Fuel Filter



Person : 1

Reference : 1







Person : 2

Reference : 2



Reporter Organization : Fractional





Events







Assessments



Narrative: 1

Climbing to FL260, Crew Alerting System (CAS) message "FUEL FLTR BYPASS R"

illuminated. Referred to QRH, stated possible fuel contamination, land as soon as possible.

[Advised ATC of the situation], determined [a nearby airport] was best airport for

emergency landing. ATC cleared direct to airport and safely landed. After landing

terminated emergency.

Narrative: 2


Synopsis

CE-680 flight crew reported diverting to an alternate after receiving Crew Alerting System

(CAS) message FUEL FLTR BYPASS R, an indication of possible fuel contamination.

ACN: 1413982 (45 of 50)

Time / Day

Date : 201612


Place



Environment


Light : Daylight

Aircraft

Reference : X






Flight Plan : IFR

Mission : Passenger




Component




Person : 1

Reference : 1











Person : 2

Reference : 2











Events









Assessments





Narrative: 1

During ground time between flights, I noticed that fueling had begun but then stopped as

there was a larger fuel imbalance in the number one tank than the amount in the tank

when we landed. Later I noted that the fueling was complete and the fuel gauges read the

required amount from the Dispatch Release. Stopping/starting refueling operations is

something I have seen on the line on numerous occasions. We successfully completed all

our normal procedures including a loadsheet review and fuel audit. We taxied and took off

with no issues.

Shortly after takeoff, I noticed that the Number One fuel gauge was suddenly reading

approximately three to four thousand pounds less than it read on the ground. Initially, I

thought this was some anomaly. On the older model 737 aircraft, it is common to have

temporary erratic indications. After a minute or so, the gauge had not corrected. I looked

over at the F/O's yoke and he was flying in a left wing down condition. I asked him if he

noticed any control problems and he stated that he felt a rolling motion in the right wing

down direction. This indicated to me that we might actually have a fuel imbalance. With

the possibility that we had a significant fuel imbalance, gauge error, and possibly not

enough fuel to get to destination (if the gauges were correct), we elected to return to

[departure airport]. I informed ATC, Operations, the Flight Attendants and the Passengers.

We immediately started crossfeed operations and ran the Off Schedule Descent QRH

Checklist. (We received the Off Schedule Descent light when we started back down into

ZZZ). We requested Maintenance and Fuelers meet us at the gate. The arrival, approach,

and landing went normally. We landed with a 2,500 pound fuel imbalance showing on the

gauges.

Back at the gate, we immediately dipsticked the tanks and confirmed that the gauge

readings were correct. We landed with a 2,500 pound imbalance and had more than 3,000

pound imbalance in flight. Somehow, the number one fuel gauge had read the proper fuel

balance before pushback and then self-corrected to the true amount later (We did not

have engines running long enough to develop an imbalance that large and there was no

evidence of a fuel leak).

Narrative: 2

The Captain and I noticed during the fuel audit that only 845 gallons were added. Based

on a 9.2 arrival FOB, the gallons added should have been approximately 1,375 gallons.

As indicated on the Fueler's sheet, the Fueler brought the fuel from 12.4 pounds to 18.4

pounds or 845 gallons. We both assumed that there were two fueling events that caused

the fuel to go from 9.2 pounds to 12.4 pounds, and then from 12.4 pounds to 18.4

pounds. The fuel readout on the FMC indicated 18.4 pounds.

Synopsis

B737 flight crew reported a significant fuel tank imbalance after takeoff and right roll

tendency. They returned to base where fuel imbalance was confirmed. An improper fuel

audit and initially inaccurate fuel gauge were cited as causes.

ACN: 1413897 (46 of 50)

Time / Day

Date : 201612


Place




Environment



Light : Daylight

Aircraft

Reference : X

ATC / Advisory.CTAF : ZZZ


Make Model Name : Amateur/Home Built/Experimental



Flight Plan : VFR


Route In Use : None


Component : 1




Component : 2

Aircraft Component : Pitot-Static System



Person

Reference : 1












Events





Result.General : Evacuated

Result.Aircraft : Aircraft Damaged

Assessments




Narrative: 1

After completing his private pilot certificate my student planned on flying his KitFox 7. An

annual conditional inspection was conducted and the owner wanted me to fly the aircraft

to gain proficiency in order to give the owner instruction in his KitFox. The annual

conditional inspection was done. I conducted a check out flight. The flight was cut short

due to engine roughness after takeoff and set back on the runway and taxied back to the

maintenance department for closer inspection. The result was the aircraft was not

receiving enough fuel at full power even with both electric fuel pumps on. After installing

check valves for the fuel system as well as replacing the fuel regulator the chief pilot and I

again tried another checkout flight.

After closer examination in flight we still had slight engine roughness at high power

settings but not nearly as bad as before. The airplane ran perfectly fine at 35 inches

manifold pressure and under and we were able to do power off stalls, steep turns, climbs

and descent as well as three takeoffs and landings in which the airplane flew normal. In

order to fix the remaining fuel issue at high power settings we adjusted the fuel pressure

to the maximum settings in order for the engine to receive more fuel needed to run at

max power. We felt confident in my handling of the aircraft and I decided to fly the KitFox

in order to gain further proficiency in the handling characteristics of the aircraft in order to

provide the best instruction for the owner. This local flight started with a thorough weather

brief from Aviation Weather Center website followed by calculations of performance and

weight and balance.

Next I conducted a thorough preflight inspection which included checking proper fuel

quantity and fuel sampling. All fuel, oil, coolant, flight controls, airframe, tires, brakes,

antennas, and lights were all in working order for a safe flight. I proceeded to pull the

aircraft out of the hangar and started the aircraft. It took several tries to start the engine

and had to use the choke in order to start the engine in the cold conditions. Once started,

engine instruments were in the green and taxied to the active after receiving the

automated weather and completing the after start checklist. Holding short of the runway I

ran the engine to 4000 RPMs and checked the left and right ignition circuits. I then turned

fuel pump B on and ran the airplane to maximum power which brought the fuel PSI to

maximum of 23 PSI but the engine ran fine. This was a good sign because until this point

the engine wouldn't run smoothly at max power settings. I brought the engine back to

4000 RPMs and checked the fuel pumps and when shutting both fuel pumps off the

airplane slowly quit and died. I restarted the engine and to confirm this was OK I taxied

back to maintenance for a second opinion. Normal operation calls for fuel pump A to be

running all the time but I wanted to ensure that the fuel system was in working order in all

fuel pump positions and thought it would be wise to have the mechanic sit in on a run up

to ensure everything was working properly. He got in on the right seat and the airplane

remained within limits from max power to idle with both fuel pumps on and with both fuel

pumps off the pressure dropped which is to be expected being gravity fed and the engine

did not shut off. He then got out of the airplane and I proceeded to taxi to the runway and

conducted another run-up at 4000 RPM with both pumps on. Everything checked out and I

entered the runway applied full power verified engine instruments were in the green and

airspeed was alive and rotated at 47 knots. I climbed at 70 knots and turned left

crosswind at 5700 ft. On left crosswind I realized my airspeed was at zero and looked onto

the left wing to see the pitot tube had rotated sideways and wasn't receiving any ram air.

My plan at this point was to return for landing and have maintenance tighten the pitot

tube. I entered the left downwind leg and was at a pattern altitude of 6000 ft. I conducted

a before landing check followed by verifying the checklist and abeam the numbers brought

the power back to 15 inches manifold pressure and began my descent. Both fuel pumps

were on at this point and listening to the engine I sensed something wasn't right and

applied power in which there was no response. I had turned left base and started to

realize I had a serious problem and proceeded directly for the runway numbers. Without

an airspeed indicator I maintained what I thought was the best glide pitch attitude and

tried to manage the energy I had left on the airplane.

The propeller was still turning but after multiple attempts of adjusting the throttle I soon

realized the engine did not have any power to give. I made one final radio call on the CTAF

frequency stating I was making an emergency landing short of the runway. There was a

small snow bank just in front of the blast pad from the snow removal conducted on the

runway. I knew I didn't want to risk running into the snow bank so I made a decision to

set the aircraft in the grass prior to the runway as soon as I cleared the airport fence. The

landing was firm but touched down on the mains first. Once the nose wheel hit I rolled for

approximately 75 ft then the nose gear collapsed and the propeller hit the dirt. I then

continued to slide for another 90 ft and the aircraft came to a stop. I ensured all fuel shut

offs and power were off and exited the aircraft from the pilots door (left door) and waited

outside the aircraft for emergency personnel to arrive.

There were many different things that may have prevented this unfortunate outcome. We

all did lots of research and we were both knowledgeable of the correct operation of the

aircraft. We also took lots of advice from the owner who was very knowledgeable and had

attended training from Rotax. We read through the engine manual and KitFox manual

several times. However I felt that the operation of the fuel system and especially the fuel

pumps were very vague in the operation manuals. I feel that more information is needed

to be available to the pilot with regards to the correct operation of the aircraft.

The pitot tube that was installed on the aircraft was in my opinion of poor design and

needed to be more secure so that it would not turn in flight. Lastly I think the snow bank

at the end of the runway did play a factor. I can't say for certain if I would have made the

runway with the bank not being there but it was a hazard that I wanted to avoid hitting

which resulted in setting the aircraft down a few hundred feet earlier than what I had to.

Synopsis

Kitfox 7 pilot reported a loss of power due to possible fuel system problems and no ram air

due to rotated pitot tube while on downwind. The pilot attempted to land well short of the

runway in the grass, and the nose gear collapsed on landing.

ACN: 1413892 (47 of 50)

Time / Day

Date : 201612


Place




Environment


Weather Elements / Visibility : Icing

Weather Elements / Visibility : Rain


Light : Daylight

Aircraft

Reference : X



Make Model Name : BAe 125 Series 800



Flight Plan : IFR

Mission : Passenger




Component

Aircraft Component : Fuel Booster Pump



Person : 1

Reference : 1








Qualification.Flight Crew : Flight Engineer





Person : 2

Reference : 2













Events








Assessments



Narrative: 1

Enroute at FL340 in cruise the FUEL 1 LOW PRESSURE light illuminated and the FUEL

lookup light came on. Performed the abnormal procedure checklist fuel low pressure

ABNORMAL procedure checklist (Ventral Tank Full). The fuel imbalance kept getting worse

[so we] descended to lower altitude, FL250. Tanks keep getting more out of balance, [so

we requested priority handling] and landed at the nearest suitable airport.

Narrative: 2


Synopsis

Hawker 800XP flight crew reported diverting to an alternate because of an increasing fuel

imbalance related to a FUEL 1 LOW PRESSURE warning.

ACN: 1413603 (48 of 50)

Time / Day

Date : 201612


Place

Locale Reference.Airport : BOS.Airport

State Reference : MA


Environment


Light : Daylight

Aircraft

Reference : X


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



Flight Plan : IFR

Mission : Ferry


Person

Reference : 1







Events







Assessments



Narrative: 1

I did not catch that the plane was not fueled as I requested before I departed BOS with

350 pounds of fuel. This was sufficient fuel for departure, but not to get to the planned

destination with 45 minute reserve. I realized my mistake just after departure and

returned to BOS for additional fuel before continuing to [destination]. This was a

repositioning flight with no passengers on board.

First Officer and I flew [many legs]. At BOS, I was informed that there were no scheduled

passengers to [our destination] and that we could leave early. I was eager to get ahead of

schedule, completed weight and balance and then went upstairs for a coffee before

proceeding to the airplane. I did not realize airplane had not been fueled.

I realize that I was eager to get ahead of schedule and that I did not complete every line

on the company start-up nor the line-up and wait checklists.

I believe that I always check the fuel quantity when flying with passengers because I am

concerned about having too much fuel and being overweight. In this case, with no

passengers, I was not concerned about too much fuel and mistakenly never considered too

little fuel.

I understand the importance of always following every line of the company checklists in all

situations. I have learned an important lesson and will be more diligent in the future.

Synopsis

Air taxi pilot reported departing with insufficient fuel to reach its destination and shortly

after takeoff returned to the departure airport.

ACN: 1412795 (49 of 50)

Time / Day

Date : 201612


Place

Locale Reference.Airport : BTV.Airport

State Reference : VT

Environment

Flight Conditions : Marginal

Weather Elements / Visibility : Icing



Light : Night

Aircraft

Reference : X

ATC / Advisory.Tower : BTV


Make Model Name : Medium Transport



Flight Plan : IFR

Mission : Passenger



Airspace.Class C : BTV

Person : 1

Reference : 1








Person : 2

Reference : 2








Events

Anomaly.Deviation - Altitude : Overshoot







Assessments




Narrative: 1

Aircraft X [operating] to CYUL with divert to BTV. I (Captain) was pilot flying. On arrival to

Montreal 24L the aircraft in front of us reported poor braking action and sliding on the

runway so we went missed. They were going to put us number four in line to try again for

24R but considering fuel and weather we decided to immediately divert to BTV. It was

very windy and turbulent on approach into BTV. On the approach at around 1000 feet we

got a red wind shear and went missed. During the execution of the wind shear missed

approach the stick shaker went off for a split second and went away due to the turbulence,

and we got the Autopilot fail message. We came back around for another attempt, at this

point we were at about 1900 Fuel on Board (FOB) and options were dwindling. On the next

attempt, at about 1000 feet, we got the red wind shear again. Considering that the wind

shear was not associated with a thunderstorm, our fuel situation, other possible alternates

within range likely to also have wind issues, and the reasonably high altitude of the wind

shear warning, I used my captain's authority to disregard the wind shear warning and

continue the approach. I put her down safely in BTV. We refueled and continued on to

Montreal.

BTV was a terrible alternate. The TAF did not look so bad but it was bad when we got

there. More fuel would have been nice to have. I overshot our missed approach altitude of

3000 feet by 3 or 400 feet because I was and fighting the turbulence with no autopilot as

it kicked off with the shaker and troubleshooting that was at the bottom of my list of

importance. Threats were mountains, winds, wind shear, runway icing in CYUL, bad

options for other alternates, and minimal fuel.

It would be nice to not always be so tight on fuel, it seems like the company often gives us

the minimum required by law and you can quickly run out of options. We diverted

immediately from Montreal and still were in a bad spot at BTV. I believe I made the

correct decision in disregarding the wind shear alert on the second approach and landing

the plane, we would have been well into reserve fuel if I went missed again. I don't

remember the winds now I'm tired and did 3 more legs after that, but it was windy,

significantly windy, and we should be more mindful of that when choosing alternates

especially at the dispatch level and also at the pilot level. And if I had more fuel I would

have gone missed again and not disregarded the second red wind shear alert. And the

dispatcher did a good job dealing with the situation with us, it was just a bad alternate.

Narrative: 2


Synopsis

Air carrier flight crew reported a diversion to BTV after runway conditions deteriorated at

CYUL. Captain reported BTV was not a very good alternate, but due to their fuel state

elected to successfully land even though he received a windshear alert on the second

approach.

ACN: 1412791 (50 of 50)

Time / Day

Date : 201612


Place



Aircraft

Reference : X



Make Model Name : EMB ERJ 145 ER/LR



Flight Plan : IFR



Person

Reference : 1








Events





Assessments



Primary Problem : Ambiguous

Narrative: 1

We had to deice [at departure station], cutting into our fuel a little bit. We were still 200

LBS over Minimum Fuel (MINF) when we took off. I messaged dispatch to see about

getting some leeway in the MINF number but they never got back to me, and we didn't

need it so we went, 200 LBS over min fuel. On climb out I noticed the prog page at 0 fuel

over destination on the climb and started looking to see if there was an error in entering

data. I could not find any. I decided to level off and assess the fuel situation, we had time.

The prog page started showing us landing about 1.4 to 1.6 when we leveled off. I

messaged dispatch to calculate fuel at fixes. We were about 400 LBS behind on the

paperwork fixes. I checked three different fixes with the dispatcher at 30 minute intervals,

and at all we were about 150 LBS over min fuel according to the dispatcher. At that point I

was comfortable that we were safe and [destination] was reporting no arrival issues and

we had a straight in runway. I saw no reason for a fuel stop considering we were over min

fuel at the fixes according to dispatch. We got in quickly and landed with I'd say 1550 to

1600 LBS fuel, both tanks and the center indicator were all in amber. Well into reserve

fuel.

I knew immediately on level off that we had fuel issues. I went to Long Range Cruise

(LRC) immediately, about 215 knots, and contacted dispatch to start talking about a plan.

We figured out fuel stop possibilities and came up with a plan to check a fix every 30

minutes to see how fuel was looking. Each fix showed we were 150 LBS over MINF. I was

comfortable going into [destination] knowing that. We got straight in, no delays and

runway was a straight in approach. Still we landed with both sides and the total fuel in the

amber. That is to me an undesired aircraft state.

Why, after being 150 LBS confirmed over MINF through dispatch at three separate fixes on

the flight plan, am I landing with 1500 to 1600 LBS gas and all my fuel gauges in the

amber at [destination]? I should not ever land in the amber unless there is an abnormal

situation, and according to the dispatcher I was still over by 150 LBS so we could have

landed and still been over min fuel according to what happened. We went straight in, no

delays. This proves to me that something is wrong with whatever system we are currently

using to calculate fuel. I came up in an environment of safety first and I think that these

fuel numbers prove empirically that something is off. We landed this flight with no

problem, but one missed approach and we would have been in serious trouble. Why does

dispatch min fuel over fixes allow me to land at worst at around 1400 LBS? I have to trust

their min fuel numbers, they are in a better position to calculate. I think the system may

be fine 90 percent of the time, but on this one we were pushing it too far. Again, why am I

over MINF by 150 at fixes and landing in the amber? Something is off and I hope the

[report] committee will look into it further.

Synopsis

EMB-145LR Captain reported landing with unusually low fuel quantity even though his

enroute fuel checks were all normal, and there were no arrival delays.

Documents

Fuel Management Issues - Aviation Safety Reporting System - NASA