Incident Boeing 737-484 (SF) ZK-TLL, Wednesday 8 June 2022
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Date:Wednesday 8 June 2022
Time:
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different    
Boeing 737-484 (SF)
Owner/operator:Toll Aviation, opb Airwork
Registration: ZK-TLL
MSN: 25362/2142
Year of manufacture:1991
Engine model:CFMI CFM56-3
Fatalities:Fatalities: 0 / Occupants: 2
Other fatalities:0
Aircraft damage: None
Category:Incident
Location:Auckland International Airport (AKL/NZAA) -   New Zealand
Phase: Landing
Nature:Cargo
Departure airport:Sydney-Kingsford Smith International Airport, NSW (SYD/YSSY)
Destination airport:Auckland International Airport (AKL/NZAA)
Investigating agency: TAIC
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Airwork flight 2, A Boeing 737-400 (SF), was involved in a low fuel incident on a cargo flight from Sydney to Auckland International Airport (AKL).

After landing at AKL and while taxiing the plane to stand, the flight crew noticed that the centre fuel tank still had 4000 kilograms (kg) of fuel, but there was minimal fuel left in the two main tanks that were feeding the engines. They discovered that the centre fuel pumps had remained off for the entire flight when they should have been selected on during the engine start procedure in Sydney.


Findings:
1. The flight crew omitted to turn on the center fuel pumps before starting the aircraft and did not detect that the fuel in the center tank had not been used until after landing in Auckland when a main fuel pump low pressure light illuminated.
2. The requirement to reprogramme and replan their departure due to a runway change and the approaching curfew added to the pressure the flight crew were under and very likely contributed to distraction when they were completing the Before start checklist.
3. If the aircraft had flown a go-around from the approach into Auckland, it is likely that the fuel in the main tanks would have been exhausted during the manoeuvre.
4. The operator’s Operations Control Centre (OCC) staff did not provide updated weather forecasts or flight plans to the crew prior to Extended Diversion Time Operation (EDTO) sectors as required by the operator’s OCC Manual.
5. The operator’s flights AWK2 and AWK82 departed for Auckland with flight plans nominating destination and EDTO alternates that were not compliant with regulatory or company flight planning requirements.
6. The regulator’s audit identified deficiencies in the operator’s safety management system, both before and after the occurrence. The regulator is monitoring the implementation of the corrective actions taken by the operator to progressively address these deficiencies.

Accident investigation:
cover
  
Investigating agency: TAIC
Report number: AO-2022-005
Status: Investigation completed
Duration: 2 years and 5 months
Download report: Final report

Sources:

https://www.taic.org.nz/inquiry/ao-2022-005

Location

Revision history:

Date/timeContributorUpdates
23-Jun-2022 09:12 harro Added
23-Jun-2022 09:12 harro Updated [Date, Time, ]
27-May-2023 01:56 Ron Averes Updated
28-Nov-2024 14:32 ASN Updated [Total occupants, Other fatalities, Location, Narrative, Accident report, ]

Corrections or additions? ... Edit this accident description

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