Air France A319 at Paris on Mar 12th 2014, engine starves due to lack of fuel

Last Update: February 21, 2020 / 11:27:09 GMT/Zulu time

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Photo of Air France F-GRHT, Airbus A319 — Air France F-GRHT, Airbus A319 (Photo credit: airlines470 / Flickr / License: CC by-sa)

Incident Facts

Date of incident
Mar 12, 2014

Classification
Incident

Airline
Air France

Flight number
AF-7665

Departure
Marseille, France

Destination
Paris Charles de Gaulle, France

Aircraft Registration
F-GRHT

Aircraft Type
Airbus A319

ICAO Type Designator
A319

An Air France Airbus A319-100, registration F-GRHT performing flight AF-7665 from Marseille to Paris Charles de Gaulle (France) with 84 people on board, was descending through FL100 on approach to Paris' Charles de Gaulle Airport when the left hand engine (CFM56) starved after both left hand fuel pumps dropped offline. The crew worked the engine failure checklists, declared emergency and continued for a safe single engine landing on runway 08L about 10 minutes later.

The French BEA reported in their weekly bulletin of May 13th 2014, that the aircraft had departed Marseille with 5000kg (11,000lbs) of fuel. A post flight inspection revealed the left hand wing tank was empty, the right hand wing tank contained 1100kg (2425 lbs) of fuel, about 150kg (330 lbs) above required minimum fuel reserve. The ECAM displayed between 1000 and 1380 kg (between 2200 and 3040 lbs) of fuel for each left and right hand wing tank.

The incident aircraft remained on the ground until Apr 2nd 2014 (for 21 days) before resuming service.

On Jan 20th 2020 the French BEA released their final report in French only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a French only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe).

On Feb 21st 2020 the BEA also released a courtesy English translation of the final report (the following is based on the French report, translated by AVH).

The report concludes the probable causes of the incident were:

At the end of the previous flight, in the absence of the first officer, an error in the captain's fuel consumption tracking calculations of about 900kg was not detected. A difference in these computations and fuel quantity indications for the left hand tank would likely have alerted the next crew to a failure of the fuel management and indication unit (FQIC).

The flight crew of the incident flight, relying on the information available to them (at the FQIC) departed for the flight without being aware of the erroneous quantity of fuel on board. When a low level alarm triggered unexpectedly the crew assumed it was a false alarm like reported by the previous crew. Subsequently whem the fuel pumps shut down and the engine stopped the crew believed both fuel pumps had failed still being convinced the fuel quantity indication was correct. The crew had no doubt about the presence of fuel in the left hand tank until after arriving at the parking stand. Technical reviews subsequently confirmed the FQIC had failed providing incorrect information about the amount of fuel present in the left hand tank.

Contributing factors were:

- the descent helped to starve the engine
- the many differences and inconsistencies in monitoring the fuel consumption by the crew following the previous flight, probably due to absence of information in the operating manual, insufficient training and lack of verification of the captain's calculations by the first officer
- the difficulty of flight crew to query information which is considered verified and provided prior to a flight (confirmation bias)
- a low fuel ECAM procedure which requires crew actions based on incorrect fuel quantity indications by FQIC and on lack of knowledge, that the low fuel level indication system and FQIC are entirely independent

The BEA reported that a flight crew had completed two sectors between Marseille and Nantes in the morning of Mar 12th 2014 and noticed a discrepancy of 300kg of fuel less than expected. Maintenance in Nantes performed a test which identified a sensor in the left fuel tank to be failing. The repair was deferred to a later date and the aircraft returned to service. The next flight to Marseille was uneventful, the captain reported a discrepancy of 20kg of fuel (based on the theoretical fuel quantity on board before the flight, the total fuel consumed during the flight according to the totalizer displays and crew computations and fuel on board after arrival). This computation however was in error, the mismatch was in fact 880kg more indicated than present.

The incident crew received indications of 3,780kg of fuel on board, decided to carry 5000kg of fuel and thus topped the tanks off by adding 1200kg of fuel. Following the refueling the FQIC showed a total of 5080 kg of fuel on board.

While climbing between FL150 and FL200 the captain noticed the two transfer valves were open, both wing tanks showed 1600kg of fuel. Still in the climb the crew received a "FUEL L WING TK LO LVL" ECAM message associated with a master caution and the automatic display of the fuel page. The crew observed the fuel quantity indication was fluctuating and stabilizing and concluded this was an untimely false alarm. Nonetheless the crew performed heightened monitoring of the fuel situation checking the fuel page every 5 to 10 minutes afterwards.

Descending through FL080 both left fuel pumps indicated low pressure following by a "ENG 1 FAIL" ECAM message. The crew performed the related checklsits, declared emergency and continued for a safe single engine landing.