As they say on TV Tropes: “Poor Communication Kills”. Incidentally, more than a few planes have crashed because crewmembers didn’t take care to ensure that their intentions or requirements were properly communicated to and understood by their crewmates, leading to situations where the two pilots were trying to accomplish different things (both of which made perfectly good sense to each of them), without realizing that the other guy would have a different idea.
The captain is the captain. He/she is responsible for the safety of the flight in every way including ensuring the correct fuel load is on board (that’s why we get the big bucks).
I was once the PiC of a piston engined Shrike Commander that was fuelled with jet fuel. The primary cause of the incident as determined by the company safety department was not the failure of the fueler to do his job properly, but the failure of the captain (me) to adequately supervise the fuelling. Everything is the captain’s responsibility.
Having said that, there was a lot going against the Gimli Glider crew that day. and it could certainly have happened to another crew faced with similar circumstances.
Reading the wiki article on it, it would seem it was both the ground crew and the pilots who made and perpetuated the error (the calculation was checked several times but always using the incorrect conversion.) It is the captain’s responsibility though, regardless of who makes the actual error.
Quite possible. I have learned that if the fueler expresses any kind of surprise at your fuel uplift, you should have a careful rethink. I was an FO on a flight when the fueler at the departure field said something like “gee that’s not much fuel, the other guys are taking twice that much.” We rechecked the destination weather forecast and found nothing unusual so took off only to be told shortly afterward that fog was rolling in at the destination. This meant we needed enough fuel to get there, fly a missed approach, and proceed to an alternate. We didn’t have that much so had to turn back to the departure airport and load more.
The other company jets flying the route were already carrying the extra fuel (hence the fueler’s surprise that we weren’t). Although the fog was not forecast to affect our arrival, the other captains were taking extra fuel due to a bit of local knowledge that Melbourne fog forecasts are unreliable. On our flight we were both new to the route and didn’t have the same level of local knowledge.
The next time I fly, I won’t.
Thanks, that is very interesting and makes sense.
In the case of the Gimli Glider, my reading is that the pilots involved (Capt Pearson and FO Quintal) took charge of the aircraft at Montreal where they relieved another crew. The outgoing crew advised them of problems with the fuel gauges and suggested they take on enough fuel to reach Edmonton at that point, since the “no fuel gauge” rules required a manual check of the tanks and that way they wouldn’t have to get that time-consuming procedure done twice.
Pearson agreed, so when he asked the fuel guy if that was a normal load for the trip, he said “It’s much more than normal.” Of course, it was more than normal to reach Ottawa, but the fueler was not aware that Pearson intended to land at Ottawa and proceed to Edmonton with that load.
The irony is that the fuel gauges worked fine if the second channel on the system was disabled. The second channel had been disabled and the fuel gauges had been working prior to Pearson taking over the aircraft but an engineer had reset the circuit breaker while trouble shooting the fault in the second channel and had failed to pull it again.
Yep. People don’t realize that most of a flight is flown by automation. Pilots are not paid to fly the plane, they’re paid to fly the plane when crap happens and to recognize crap before it gets out of hand and do something about it. Which makes the Asiana flight to SFO all the more worrisome. That was the equivalent of exiting the highway in an 18 wheeler at 100 mph on ice. ANYBODY in the cockpit would have realized the glide slope was way off and yet they let it happen.
I rarely see a captain watch or even note the fueling of an airplane. They could pull up in a truck marked “baby formula” and few crews would realize it.
What’s interesting about most aviation incidences is that it’s usually a series of mistakes that add up. Rarely is it a single event.
I used to talk about this in fault tracing class. The fault was noted and diagnosed as a bad fuel totalizer unit in Vancouver. The technician correctly found that by pulling the breaker on one channel the gauges worked correctly. (There was a cold solder joint in that channel causing and erroneous voltage reading which knocked the system out if that channel was energized.)
He wrote it up, ordered the part, and noted that the tanks had to be “stuck” (manual calculation of the amount of fuel on board), and left the breaker off so the gauges worked.
The next AM the plane flew to the east coast no problem. The gauge worked on one channel and they had put in the correct amount of fuel.
That night the fun began. The tech that night saw the bitch written up and instead of looking at the gauge first found a turned off breaker and flips it on. He saw the gauge didn’t work shrugged his shoulders and went on about his business.
If he had looked at the gauge before he flipped the breaker, or had turned the breaker back off the plane would have had a functional fuel gauge.
The lesson here is you need to THINK when fault tracing. In this case he should of thought why is this breaker off? This is not normal so why is it off?
Interesting side note on this case. Air Canada dispatched a team of technicians to start the repair of the plane. They flew to the nearest airport served by AC hopped into a van to drive out to Gimli. On the way there the van ran out of gas. [Homer Simpson] DOH! [/HS]
A lot of the time it would be impractical for the captain to directly supervise the refuelling. Being responsible for ensuring that the correct quantity and grade of fuel is delivered doesn’t necessarily mean you have to supervise, it depends on the company procedures. At major airports we have ground staff who are qualified to conduct fuelling themselves or to supervise the fueler. As the captain I can ensure the correct grade and quantity has been delivered by checking the fuel docket and ensuring the FO does a fuel calculation (fuel remaining plus fuel added should equal fuel on the gauges to within 3%.) In our company the captain is responsible for ensuring that all of the aircraft safety equipment has been checked prior to flight but that doesn’t mean we have to check it ourselves, the company procedures delegate the task to the cabin crew and when they report to the captain that all checks are complete that satisfies the requirement.
Very much so. For my fuelling incident the following things had, in my opinion, been factors.
[ul]
[li]Company manuals stated fuelling must be directly supervised by the crew unless the fueler was a company contracted fueler. The company had a list of “preferred” fuel suppliers at each airport that I thought constituted a list of contracted fuel suppliers, they weren’t. It turns out the “contracted fuel supplier” clause was a left over from the parent company’s manuals and the subsidiary company had never had contracted fuel suppliers as defined in the manuals.[/li][li]Nobody, including check and training pilots, management pilots, etc, directly supervised refuelling because it was impractical due to the nature of our operation (we were often arriving and departing outside of normal work hours so fuel orders would be phoned through to the fueler and quantity and grade would be checked prior to the flight.)[/li][li]The fueler who fuelled my Shrike was new to the job.[/li][li]I knew this and asked him if he’d refuelled this type of aircraft before. He said he’d done one the previous day.[/li][li]It turns out that the Shrike he’d fuelled the previous day was a turbine engined model that takes jet fuel.[/li][li]The fuel grade markings next to the fuel caps on our aircraft had faded and were difficult to read.[/li][li]I didn’t supervise. [/li][/ul]
There were several more chances to catch the error before we tried to fly. After the fuelling I would have received the fuel docket and would have checked the grade. During the pre-flight inspection I would have done fuel drains and checked the grade then. If neither of those processes had caught the error we probably would have suffered a double engine failure out in the middle of nowhere. As it was, the fueler realised his error when he started fuelling the second tank which had a newer fuel grade sticker on it.