Aviation safety investigations & reports

Fuel related event - 50 km NW of Swan Hill, Vic; 11 August 2007; VH-TJE, Boeing 737-476

Investigation number:
AO-2007-036
Status: Completed
Investigation completed

Summary

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On 11 August 2007, a Boeing Company 737-476 aircraft, registered VH-TJE, was being operated on a scheduled passenger service from Perth, WA to Sydney, NSW. The flight crew consisted of a pilot in command, who was the pilot flying, and a copilot. The aircraft departed from Perth at 0544 Western Standard Time. About 2 hours 40 minutes later, the master caution light illuminated associated with low output pressure of the aircraft's main tank fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position.

The main fuel tanks were low on fuel and the investigation estimated that there was about 100 kg in each of the main tanks. The centre fuel tank contained about 4,700 kg of fuel when the master caution occurred. The flight continued on the flight planned route and landed at Sydney 51 minutes after the initial illumination of the master caution light.

The investigation determined that the flight crew had flown the previous two sectors on a B737 aircraft with a different fuel system and fuel control panel. The pilot in command was suffering from chronic stress and it is probable that this stress affected his ability to operate as a pilot in command without him being aware of this. In addition, some checklist procedures were not adhered to by the flight crew and it was likely that deviations from those checklist items were occurring throughout the operator's fleet of B737 aircraft.

As a result of this investigation, the operator has instigated safety action to change the Before Start and Before Taxi procedures and checklists.

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Preliminary

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Preliminary report released 11 October 2007

On 11 August 2007, a Boeing 737-476 aircraft, registered VH-TJE, was being operated on a scheduled passenger service between Perth, WA to Sydney, NSW. The flight crew consisted of a pilot in command, who was the pilot flying, and a copilot. The aircraft took off from Perth at 0544 Western Standard Time. About 2 hours 40 minutes later, the master caution light illuminated associated with low output pressure of the aircraft's main tank fuel pumps. The pilot in command observed that the centre tank fuel pump switches on the forward overhead panel were selected to the OFF position and he immediately selected them to the ON position.

The main fuel tanks were low on fuel and the investigation estimated that there was about 100 kg in each of the main tanks. The centre fuel tank contained about 4,700 kg of fuel when the master caution occurred. The flight continued on the flight planned route and landed at Sydney 51 minutes after the initial illumination of the master caution light.

Download Preliminary Report
[Download  PDF: 450KB]
 
 
 
General details
Date: 11 August 2007   Investigation status: Completed  
Time: 1200 EST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): 50 kms NW of Swan Hill    
State: Victoria   Occurrence type: Fuel - Other  
Release date: 28 July 2009   Occurrence category: Serious Incident  
Report status: Final   Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer The Boeing Company  
Aircraft model 737  
Aircraft registration VH-TJE  
Serial number 24430  
Type of operation Air Transport High Capacity  
Damage to aircraft Nil  
Departure point Perth, WA  
Departure time 0544 WST  
Destination Sydney Airport  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 10705 19611
Co-Pilot/1st Officer ATPL 2918 5026
Last update 14 November 2018