Fuel pumps left

in OFF position

By: Frédéric COMBES

Director, Flight Safety

1 Introduction The following data have been investigated:

• Engines Full Authority Digital Engine Control
(FADEC) Non Volatile Memories
An A320 encountered a dual engine rollback, after • Digital Flight data Recorder (DFDR) engine main
the aircraft levelled off at Flight Level 380, as a parameters
result of fuel starvation. • Post Flight Report (PFR).
The aircraft was dispatched with the center tank
empty. Both wing tank fuel pushbutton switches Analysis of all the available data allowed to rule
had been left in the OFF position from engine start. out the first four hypothesis.
Interesting lessons may be learned from this event. Indeed:
• There was no indication that inclement weather
condition could have contributed to the event
• The fuel sampling analysis confirmed that the
2 Investigation fuel was not contaminated
• The data recorded within the engine computer
allowed to rule out any control system/engine
An official investigation was conducted with the issue
concerned Investigations Board, the airline, engine • The aircraft’s recorded data and troubleshooting
supplier and Airbus. performed on the aircraft, did not highlight any
evidence of failure in the following systems:
Five different hypothesis have been examined: – Fuel
• Adverse weather conditions – Electrical generation and distribution
• Fuel contamination – Autoflight.
• Aircraft fuel system anomaly
• Engine misbehaviour The only remaining scenario was therefore that
• Fuel pumps left in the OFF position. all fuel pumps had remained switched-off from
the engine start until the time of the dual engine
rollback.

Safety first #07 February 2009 - 1/7

The available data allowed
to confirm the following:
3 Analysis
1) During the engine start sequence all fuel of the event
pumps were left in the OFF position, leading
to the triggering of the following ECAM
Cautions: Operations Engineering Bulletin 178
“OPERATION OF CENTER TANK
FUEL L TK PUMP 1+2 LO PR PUMPS”
FUEL R TK PUMP 1+2 LO PR The OEB was applicable to the aircraft concerned
by this event. During the refuelling, all fuel pumps
The crew cleared both Cautions but left the fuel were set to OFF, in accordance with OEB 178.
pumps in the OFF position.
As a consequence, both engines were being This OEB was issued to avoid having the center
gravity fed during the engine start, take-off and tank pump in operation if not fully immersed.
climb phases of the flight. It calls for:
• All fuel pumps to be in the OFF position before
2) The behaviour of the engines was normal until and during the refuelling
the aircraft reached FL380, some 23 minutes • The wing tank pumps to be set ON after the
after take-off. At that point, both engines rolled refuelling
back, leading to: • The center tank pumps to be left OFF, if the total
• The Mach Number to decrease from M0.78 fuel on board is less or equal than 12 000 kg.
to M0.63
• The disconnection of the Electrical Generators Note: 1. OEB 178 is applicable to some
1&2 (Engines 1&2 N2 being below 53%) A318/A319/A320 aircraft with a
• The Ram Air Turbine deployment (Emergency center tank.
Electrical Configuration).
2. OEB 180 “OPERATION OF FUEL
3) The aircraft started to descend and the crew PUMPS”, applicable to some
declared an Emergency. A321 aircraft, was also issued to
At FL 320, the engines were recovered leading avoid having wing fuel pumps running
to an automatic re-connection of both Electrical if not fully immersed during fuel
Generators. The crew then decided to turn back loading operation: It notably calls for
to the departure airport where an uneventful all wing fuel pumps to be turned OFF
landing was performed. before refuelling.
This scenario was confirmed through a flight
test done on an Airbus A320 production aircraft.

Safety first #07 February 2009 - 2/7

 A318 FEB 08
A319
A320
A321
OEB PROC N° 178/1 6.00
PAGE 3 OF 6

OPERATION OF CENTER TANK PUMPS (cont'd)

PROCEDURE A (CONT'D)
CENTER TANK PUMPS OPERATION
WARNING
Do not turn on the center tank pumps, if the center tank contains less than 2 000 kg
(4 500 lb) of fuel, even if it is requested by another procedure.
Before and during refueling:
ALL TK PUMPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFF

• IF THE TOTAL FOB AFTER REFUELING IS LESS THAN OR

EQUAL TO 12 000 KG (26 500 LB)
After refueling:
- CTR TK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CHECK EMPTY
It fuel remains in the center tank, it must be considered unusable
- L and R TK PUMP 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ON
- CTR TK PUMP 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . MAINTAIN OFF
- FUEL MODE SEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . MAN

Note : The QRH OEB PROC N° 178 gives a The excess air vents into the fuel tanks and engine
quick access to the OEB procedure, fuel lines.
which is also covered in AFM TR - At some point, the quantity of vapour present in
4.03.00/28 issue 2. the fuel, when it reaches the engine, may exceed
the engine inlet maximum allowable vapour /
Limitations of fuel gravity feed liquid ratio and the operation of the engines is
The altitude limitations linked to gravity feed are compromised. In the example illustrated in this
due to the application of Henry’s law. The law article, the airplane was able to reach FL380
states that the concentration of a solute gas in a before the engines eventually rolled back.
liquid is directly proportional to the partial pressure
of that gas. However, the precise altitude at which engines will
Therefore, as the airplane climbs and as the experience fuel starvation depends on a number
atmospheric pressure decreases, so does the of factors, including saturation level of air in the
amount of air dissolved in the aircraft’s fuel. fuel, temperature and rate of climb.

Safety first #07 February 2009 - 3/7

Considering the worst case operating conditions, The PNF then performs the action and requests
the A320 FCOM 3.02.28/QRH 2.09 paper permission to clear the failure.
procedure has retained three different scenarios: The PF will first check to ensure that the action has
• The airplane is on gravity feed shortly after take- been completed, then announce, “Clear ECAM”.
off, in which case the gravity fuel feed ceiling is
limited to FL150 or 7 000 feet above the airport Fuel pumps left in OFF position
• The airplane switches to gravity feed with a Flight The following three barriers were available to
time above FL300 being less than 30 minutes, alert the crew of the abnormal configuration they
in which case the ceiling is limited to FL300 were flying in:
• The airplane switches to gravity feed with a Flight
time above FL300 exceeding 30 minutes, in • First barrier:
which case the ceiling is the current FL. At the beginning of the Cockpit Preparation
checklist for the Overhead Panel, the SOPs
request the crew to extinguish all white lights
4 Standard Operating (pushbutton switches) on the overhead panel,
as applicable during the scan sequence. This
Procedures ensures that both the center tank and wing tank
pushbutton switches are selected to the ON
ECAM task sharing rules position prior to flight, except for the center
This event serves to highlight the importance tank if OEB 178 applies.
of adhering to the ECAM operational philosophy. With the center tank and wing tank fuel pumps
The first pilot, who notices an ECAM Caution or l in the OFF position, this is how the overhead
Warning, announces the title of the failure. The panel would look like; notice the six illuminated
Pilot Flying (PF) then orders “ECAM Action”, and white pushbutton lights:
the Pilot Non Flying (PNF) confirms the action.
This process ensures that both
crew members are aware of the
failure, and that they share a
common understanding of the
actions to be undertaken.

Safety first #07 February 2009 - 4/7

• Second barrier: in the OFF position, the dedicated ECAM
30 seconds after the first engine start (flight Caution will trigger, and the FUEL page will be
phase 2), if the wing tank fuel pumps are still displayed:

(ECAM upper display

– E/WD – Warning part)

Symbol means:

PUMPS OFF

(ECAM lower display SD)

• Third barrier:
Clearance of an ECAM Caution leads to the
display of the STATUS page:

STATUS
FUEL GRVTY FEED INOP SYS
FUEL PUMPS
CTR TK FUEL UNUSABLE

Safety first #07 February 2009 - 5/7

5 Enhancements 6 Conclusion
Flight warning Computer (FWC) Existing barriers (white lights on the overhead
Airbus is working on future enhancements in the panel, ECAM Caution, audio warning, status page
next FWC standard H2F5 (certification planned display on the System Display) were available to
by mid 2009). Indeed, the TAKE OFF CONFIG prevent the crew overlooking the fuel pumps in
will be improved to monitor as well the fuel the OFF position.
pumps, hydraulic pressure, IDG disconnection,
and electrical generators. Further barriers will be included with the proposed
For example, if the fuel pumps are left in the OFF enhancements:
position, this new FWC standard will recall the • Addition of some system monitoring within FWC
following ECAM Caution : standard H2F5
• Cancellation of OEB 178 and OEB 180 with the
FUEL L TK PUMP 1+2 LO PR implementation of the modification referenced
FUEL R TK PUMP 1+2 LO PR in SB 28-1159-00.

Information concerning OEB 178 Additionally, the following more general lessons
and OEB 180: may be learned from this event:
Operators for which OEB 178 and/or OEB 180 • ECAM task sharing rules should be followed
apply, may cancel them by the accomplishment before clearing Cautions or Warnings
of the mandated Service Bulletin 28-1159-00 (this • Design features are not meant, and never will,
SB involves only 2 hours of elapsed time). to replace effective briefings.

Safety first #07 February 2009 - 6/7

 Safety First
The Airbus Safety Magazine
For the enhancement of safe flight through
increased knowledge and communications.

Safety First is published by the Flight Safety Department mandated requirements or technical orders. The contents
of Airbus. It is a source of specialist safety information do not supersede any requirements mandated by the State
for the restricted use of flight and ground crew members of Registry of the Operator’s aircraft or supersede or amend
who fly and maintain Airbus aircraft. It is also distributed any Airbus type-specific AFM, AMM, FCOM, MEL
to other selected organisations. documentation or any other approved documentation.

Material for publication is obtained from multiple sources Articles may be reprinted without permission, except where
and includes selected information from the Airbus Flight copyright source is indicated, but with acknowledgement
Safety Confidential Reporting System, incident and to Airbus. Where Airbus is not the author, the contents of
accident investigation reports, system tests and flight the article do not necessarily reflect the views of Airbus,
tests. Material is also obtained from sources within the neither do they indicate Company policy.
airline industry, studies and reports from government
agencies and other aviation sources. Contributions, comment and feedback are welcome. For
technical reasons the editors may be required to make editorial
All articles in Safety First are presented for information changes to manuscripts, however every effort will be made
only and are not intended to replace ICAO guidelines, to preserve the intended meaning of the original. Enquiries
standards or recommended practices, operator- related to this publication should be addressed to:

Airbus
Product Safety department (GS)
1, rond point Maurice Bellonte
31707 Blagnac Cedex - France
Fax: +33(0)5 61 93 44 29
[email protected]

Safety First
# 07 February 2009
Safety First is published
by Airbus S.A.S
1, rond point Maurice Bellonte
© Airbus S.A.S. 2009 – All rights reserved. Confidential and proprietary documents.
31707 Blagnac Cedex / France
By taking delivery of this Brochure (hereafter “Brochure”), you accept on behalf of your
Editor:
company to comply with the following guidelines:
Yannick Malinge,
Vice President Flight Safety > No other intellectual property rights are granted by the delivery of this Brochure than the
right to read it, for the sole purpose of information.
Concept Design by
MULTI MEDIA SUPPORT 20090053 > This Brochure and its content shall not be modified and its illustrations and photos shall
not be reproduced without prior written consent of Airbus.
Computer Graphic by Quat’coul
> This Brochure and the materials it contains shall not, in whole or in part, be sold,
Copyright: GSE 420 0046/09
rented, or licensed to any third party subject to payment.
Photos copyright Airbus
This Brochure contains sensitive information that is correct at the time of going to press.
Photos by
This information involves a number of factors that could change over time, effecting the
ExM: Hervé Berenger, Philippe
true public representation. Airbus assumes no obligation to update any information contained
Masclet, Hervé Goussé.
in this document or with respect to the information described herein.
Photo copyright Germanwings
Airbus SAS shall assume no liability for any damage in connection with the use of this
Computer rendering by ABAC
Brochure and of the materials it contains, even if Airbus SAS has been advised of the
Printed in France by AMADIO likelihood of such damages.

Safety first #07 February 2009 - 7/7