latent critical fuel
scenarios capt. raimund zopp
flugwerkzeuge aviation software
• Airbus 310, Charter flight from Chania/Greece to
Hannover/Germany
• Landing gear retraction fault at takeoff in Chania
• Flight continuation to reach commercially favorable alternate
• fuel planning exclusively by FMS
• Repeated replanning to MUC and then to VIE after FMS fuel
prediction deteriorates
• Early start of descent 90NM before optimum
• Fuel below original final reserve and fuel low level warning abeam
ZAG, 133NM out of VIE
• Emergency declared 8 minutes later
• Both engine flame-out short before outer marker
• Crash landing on grass 500m before runway
• Only light injuries, aircraft written off
HLF 3378 (Vienna, July 2000)
HLF3378 Flightpath Overview
35,00
36,00
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15,00 16,00 17,00 18,00 19,00 20,00 21,00 22,00 23,00 24,00 25,00 26,00
Longitude
Latitude
Reconstr
ACARS
Airports
DR_Path
CFPWpts
SRKOR
VIE
GRZ BUD
MBX
ZAG
SPL
DBV
BDS
CFU
SKG
ATH
CHQ
TIA
aber jetzt hamm wir
800 Kilo (CVR/CM1)
Fuel low level
warning (ACARS)
EFOB VIE below Holding
Fuel (Estimate)
FQ below Holding
fuel (Estimate)
HER
• Aircraft operated beyond range
capability with landing gear down
• FMS fuel predictions used as sole
means of fuel planning
• No ground support for fuel planning
• Subtle loss of situational awareness
• Violation of rules in final stage:
no diversion to ZAG or GRZ when fuel
quantity dropped below final reserve
official report should be available soon on
http://versa.bmvit.gv.at
HLF 3378 (Vienna, July 2000)
HLF3378 Fuel Situation
-500
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
09:30:00 09:45:00 10:00:00 10:15:00 10:30:00 10:45:00 11:00:00 11:15:00 11:30:00
UTC
Est FQ on Indicators
EFOB MUC / FMS
EFOB VIE / FMS
30 min Holding Fuel
Tanks Empty
abeamZAG
FQ Low Level Warning
EFOB VIE goes
below Holding Fuel
• repeated replanning and shortcuts gave impression that FMS fuel prediction was still reliable
• documentation confusing and incomplete
• no other method for fuel planning considered
swiss cheese model of accident causation
according to j. reason
in the case of HLF3378, active inflight support from dispatch would have been one of the
defense layers
one of several safety recommendation:
(free translation from German language, since official translation not yet available)
....
application of support to cockpit crew by the flight dispatcher as
required by ICAO Annex 6 and the quality manual of the operator
....
remaining crucial questions:
• is the dispatcher obliged to support the flight crew only on request ?
• does his support involve a fuel recalculation ?
• can (or shall) the dispatcher initiate an emergency ?
• how shall a dispatcher perform the neccessary calculations ?
HLF 3378 accident investigation
HLF3378 - just a singular case?
• actual case: gear-down diversion due to weather /
hydraulic loss
– loss of hydraulic system early during flight
– continuation to destination with approaching frontal weather
– go-around due to weather
– gear retraction impossible
– diversion with gear down
– severe fuel situation / landing below final reserve
– loss of gear retraction capability was known for hours
– documentation gives no advice to adjust fuel planning
• potential case: engine fail with locked rotor
– quiz: how much does the fuel burn increase?
commercial pressure as a risk factor ?
2000/07/12 HFL3378
• prolonged gear down flight
from Greece to Vienna
• uncritical weather
• good communication
• strong commercial
motivation to continue
• insufficient ground support
• loss of situational
awareness
• all engine flame-out
• crash
2005/02/19 BA268
• with a failed engine from US
west coast to UK
• uncritical weather
• good communication
• strong commercial motivation
to continue
　
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