ASN Wikibase Occurrence # 269280
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| Date: | Monday 25 October 2021 |
| Time: | 10:10 UTC |
| Type: |  Boeing 737-838 (WL) |
| Owner/operator: | Qantas |
| Registration: | VH-VZT |
| MSN: | 34186/3798 |
| Year of manufacture: | 2011 |
| Fatalities: | Fatalities: 0 / Occupants: 94 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | near Esperance, WA -
 Australia
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Perth Airport, WA (PER/YPPH) |
| Adelaide Airport, SA (ADL/YPAD) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
Qantas flight QF888, a Boeing 737-838 was en route between Perth and Adelaide, Australia, when the flight crew received a fuel imbalance warning. During completion of the associated checklists, the flight crew conducted a precautionary shutdown of the affected engine. The aircraft was diverted to Kalgoorlie-Boulder Airport, Western Australia and landed without further incident.
Contributing factors
- Under instruction from the engineer, the flight crew conducted steps to perform a ground transfer of fuel (to remove cold soaked fuel frost from the wings) without referring to the relevant procedures. Consequently, an error was made in not closing the fuel crossfeed valve before flight.
- During pre-flight checks, and later during the climb and level-off, the flight crew did not notice the crossfeed selector in the open position or the associated dimmed blue indicator light on the fuel panel.
- The Boeing 737 IMBAL (imbalance) checklist did not provide sufficient guidance for a flight crew to identify an open crossfeed valve as being a potential reason for a fuel imbalance.
- Partly as a result of confirmation bias, stress and perceived time pressure, the flight crew abbreviated the relevant checklists. As a result, the flight crew’s calculation of the rate of fuel imbalance change was invalid, and they misdiagnosed the fuel imbalance as being the result of a fuel leak, resulting in an unnecessary inflight engine shutdown.
Accident investigation:
 |
|
Sources:
http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-043/
https://www.flightradar24.com/data/aircraft/vh-vzt#29a15383
History of this aircraft
Other occurrences involving this aircraft
| 22 January 2023 | VH-VZT | Qantas | 0 | 208 NM 229 degrees from Nadi International Airport |  |
non |
| Inflight smoke | ||||||
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 31-Oct-2021 18:43 | harro | Added |
| 31-Oct-2021 18:48 | harro | Updated [Date] |
| 07-Jun-2022 19:50 | Ron Averes | Updated [Location] |
| 28-Feb-2024 13:45 | ASN | Updated [Narrative, Accident report] |
Corrections or additions? ... Edit this accident description
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