Flight Crew Air Transport Pilot (ATP)
Workload; Training / Qualification; Distraction; Human-Machine Interface
Aircraft Equipment Problem Critical; Deviation / Discrepancy - Procedural MEL / CDL; Deviation / Discrepancy - Procedural Published Material / Policy
Flight Crew Took Evasive Action; Flight Crew Overcame Equipment Problem; Flight Crew Inflight Shutdown; Flight Crew Became Reoriented
Procedure; Manuals; Human Factors; Aircraft; Chart Or Publication
Aircraft arrived late. We met incoming crew as they departed the aircraft and received a brief on its problems. Cockpit preflight was delayed while mechanics struggled with the required fuel transfer/refueling procedures due to inoperative Tank 3 quantity indication. Subsequently did cockpit preflight and setup; including a thorough review of lengthy MEL pages; the need to verify a voided cargo space; for an external air start (no APU); and to re-initialize the FMS data after engine start. Also reviewed autothrottles-off takeoff procedures; the SID; and the Engine Out procedure. Originally planned to start all 3 engines in chocks to simplify things; but Ground Maintenance started the huffer earlier than we anticipated and then advised us of a time limit on the huffer. Changed plans to start Number 3; disconnect the huffer; then push back and subsequently crossbleed start the others. In an intentional attempt to keep things slow; methodical; and controlled; I cut the ground crew free and then proceeded to complete the After Start Checklist; re-initialize the FMS data; configure the aircraft and complete the Before Takeoff Checklist to the line. It was during this phase that I failed to ensure the engine fuel pumps were turned on as part of the After Start Checklist with the fuel panel in manual control. Ground tried to give us 25R for departure (the short runway); which I declined in favor of the longer 25L. Subsequently departed from 25L; executed a normal departure and was climbing out on the departure. Passing through FL180; I noticed some wake-turbulence type bumps which lasted longer than normal. Began to look at engine vibration values and noticed Number 2 spooling down. Then the Low RPM alert came on. We were in the clear and the aircraft was flying fine; still climbing. Scanned further and quickly discovered the fuel pumps were OFF. We had precipitated this event by failing to turn them on while still on the ground. Confident that nothing else was amiss; we used the QRH to restart the engine; and restored it to normal operation. We reviewed our status and the Flight Operations Manual: Everything was working fine (except for the MEL'ed items); and nothing appeared to require a turn back or divert elsewhere. We elected to continue the climb toward [destination]; and sent Dispatch an ACARS message informing them of the inadvertent flameout; and intent to continue to the filed destination. Dispatch acknowledged receipt of the message with no further instructions. Continued the rest of the flight uneventfully. I wrote a Maintenance Log entry as required by the FOM; and spoke with Chief Pilot upon arrival. Obviously; even greater attention to detail is required on my part. Even though we caught and trapped several potential errors on this particular flight; none of that matters because this still happened -- and I should have caught it. I was the Captain; and the responsibility for this mistake is all mine. I can pretty confidently state that it won't happen to me a second time; but that won't change the classic setup for this kind of error. The MD-11 fuel system is fully automatic almost all of the time. When this type of MEL is employed to dispatch the aircraft; the flight crews absolutely will be entering a procedural regime into which they rarely venture; and it's full of possible human-error traps. I would strongly recommend significantly limiting other MELs when the fuel indicating MEL is employed. All four of the MELs on this flight required flight crew attention and action; compounding the probability of missing something. That could easily save crews from other errors; but probably the most effective prevention for this specific recurrence would be to add two crewmember verification to the position of the fuel pump switches when operating in Manual Mode.
Once operations were back to normal; I reviewed the Before Start Checklist and found my mistake. I had skipped over that portion of the checklist; just as I have for the past two years. At the time of the event; we were talking to Center. We had been cleared to climb to FL290. We never leveled off; and did not have a frequency change. I do not believe I have operated the Fuel System in Manual since my Initial training in the MD-11. Complacency in reading the checklist was a large factor. Other factors were the other abnormal procedures that caused distractions; the late departure as well as the late arrival of paperwork.A note or possibly even a Warning in the MEL might have prevented me missing the Fuel System Manual Operation items in the checklist. Having a Fuel System Manual during yearly training would have been beneficial.
A MD-11 Number 2 Engine flamed out in flight because an MEL required the fuel system be operated in the Manual Mode and the fuel pumps were never turned on. The flight continued after an inflight restarted.