Fuel related event - 50 km north-west of Swan Hill, Victoria, on 11 August 2007, VH-TJE, Boeing 737-476

AO-2007-036

Preliminary report

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.

Summary

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.

Occurrence summary

Investigation number AO-2007-036
Occurrence date 11/08/2007
Location 50 kms NW of Swan Hill
State Victoria
Report release date 28/07/2009
Report status Final
Investigation level Systemic
Investigation type Occurrence Investigation
Investigation status Completed
Mode of transport Aviation
Aviation occurrence category Fuel - Other
Occurrence class Serious Incident
Highest injury level None

Aircraft details

Manufacturer The Boeing Company
Model 737
Registration VH-TJE
Serial number 24430
Sector Jet
Operation type Air Transport High Capacity
Departure point Perth, WA
Destination Sydney Airport
Damage Nil