Narrative:

Our aircraft was fueled in toronto for a return trip home to yip. The fuel order was given in gallons and I watched the fueler put the requested amount in each wing. On checking the quantity gauges however, the aircraft had considerably less fuel on board than I expected to see, and also a large split in quantity between the left and right wing tanks, even though prior to fueling they had equal amounts, and the same amount of fuel had been pumped into each side. Because I had actually watched the fuel delivered, I thought it was a gauge problem and decided to depart toronto instead of getting more fuel. I had also calculated that even if the gauges were correct, we could make it with careful fuel management. En route, the fuel level in the left wing dropped to zero and we realized that the gauges had been correct, even though I still couldn't figure out what had happened to the fuel I had seen put on our aircraft. We had decided prior to departing toronto that if necessary, we would land instead in phn which looked on the map like a good halfway point. Instead of landing in phn however, we decided that if ATC would agree to vector us directly to yip and allow us to stay at altitude, we would continue to our original destination, knowing that we would land without legal reserves. I told ATC that we were having a minor problem with the aircraft and that although we were not declaring an emergency and were not requesting priority handling, we would appreciate anything they could do to expedite our arrival into yip. On arrival at yip, the aircraft had approximately 20 mins fuel on board. We asked the company mechanics to check the fuel quantity gauges for accuracy, and look for a leak somewhere that would have caused us to lose such a large portion of the fuel I had seen delivered into the aircraft. Finally, one of the mechanics commented that I had probably received liters rather than gallons, and I realized that this was indeed what had happened. 1) I was completely unaware that canada fuels aircraft in liters not gallons. Several of the decisions I made were based incorrectly on the assumption that the requested amount of fuel had been delivered. Because I actually watched the fueler and the truck meter during fueling, I was convinced the aircraft had received the fuel and that my quantity gauge was wrong. Contributing to this conclusion was the fact that earlier in the day in memphis we also had a large split between right and left tanks, even though in memphis the total fuel quantity had been correct. If I had not actually seen the fueler pump the gas I would not have hesitated to question our fuel load. The fuel receipt showed 'liters delivered' but I did not notice it. The safest course of action even though I was 'sure' I had adequate fuel on board would have been to take on more fuel. I have no idea why neither I nor my copilot insisted on doing this. 2) when we realized we were running low on fuel, and that the gauges had been correct, I opted to press on to our home airport rather than landing immediately. At that point, even though I knew we would land without legal reserves, I felt certain we could make it home. I think part of my reluctance to divert was that I didn't want to go through the hassles (customs notification) and repercussions I felt would come from landing short of the destination. I think I felt I could get the aircraft safely home, the fact that I had made such a bad decision leaving toronto without adequate fuel would not become an issue. Also, I still thought we had a maintenance problem with the aircraft, and felt that if I had landed in phn instead of yip, I would have to ground the aircraft there. If ATC would not have cooperated, if the airport was IFR, or if I had any doubt of making it safely to yip, I would have diverted immediately and accepted the consequences. 3) in discussing this situation after the fact we have idented a severe problem with both myself and my copilot in our CRM. Although we carefully discussed our actions and options throughout the incident, we both failed to properly practice good CRM. Apparently, the copilot was extremely uncomfortable with several of my decisions, but never stated that. Instead he offered suggestions (such as selecting a diversionary airport prior to departing toronto), and hoped I would take the hint. I, as the captain, kept showing the first officer what my reasoning was, and essentially kept 'selling' my point of view, and convincing him to go along with me instead of re-thinking my decisions. Although I knew he was uncomfortable, I kept showing him the logic of my decisions in order to make him more comfortable instead of taking another course of action. 4) while I don't remember being tired, I feel that fatigue and 'get-home-itis' have to have contributed to the poor decision making in this case. We had been on duty since XA30 pm the prior evening, and it was almost XB30 am as we left toronto. We had been very busy at our company lately, often flying 14 hour duty days, and going right back out again to fly immediately after our required rest period for several days in a row. We had also been waiting in the airplane for about 1 hour for the fuel truck. The decision to press on in toronto instead of getting more fuel was so uncharacteristically foolish, I can only guess that fatigue had something to do with it. As for corrective action, I am now aware that canada fuels in liters not gallons, and will be more aware of that fact in the future in any foreign country I fly to. Both myself and my copilot have learned that we need to work on our CRM. He should have voiced his concerns instead of hinting and should have communicated his discomfort instead of going along with me. I should have been more aware of his reluctance even if he didn't state it outright, and should have realized at some point in my 'sales pitch' that I needed to rethink my decision.

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Original NASA ASRS Text

Title: FALCON 20 ACFT BEING FUELED AT FOREIGN ARPT UNDER RPTR CAPT OBSERVATION. RPTR DIDN'T NOTICE FUEL BOARDED WAS IN LITERS VERSUS GALLONS AND THEN ASSUMED THE FUEL GAUGES WERE ERRONEOUS. FLC DEPARTED AND MADE IT TO DEST, BUT LANDED WITH ONLY 20 MINS OF FUEL.

Narrative: OUR ACFT WAS FUELED IN TORONTO FOR A RETURN TRIP HOME TO YIP. THE FUEL ORDER WAS GIVEN IN GALLONS AND I WATCHED THE FUELER PUT THE REQUESTED AMOUNT IN EACH WING. ON CHKING THE QUANTITY GAUGES HOWEVER, THE ACFT HAD CONSIDERABLY LESS FUEL ON BOARD THAN I EXPECTED TO SEE, AND ALSO A LARGE SPLIT IN QUANTITY BTWN THE L AND R WING TANKS, EVEN THOUGH PRIOR TO FUELING THEY HAD EQUAL AMOUNTS, AND THE SAME AMOUNT OF FUEL HAD BEEN PUMPED INTO EACH SIDE. BECAUSE I HAD ACTUALLY WATCHED THE FUEL DELIVERED, I THOUGHT IT WAS A GAUGE PROB AND DECIDED TO DEPART TORONTO INSTEAD OF GETTING MORE FUEL. I HAD ALSO CALCULATED THAT EVEN IF THE GAUGES WERE CORRECT, WE COULD MAKE IT WITH CAREFUL FUEL MGMNT. ENRTE, THE FUEL LEVEL IN THE L WING DROPPED TO ZERO AND WE REALIZED THAT THE GAUGES HAD BEEN CORRECT, EVEN THOUGH I STILL COULDN'T FIGURE OUT WHAT HAD HAPPENED TO THE FUEL I HAD SEEN PUT ON OUR ACFT. WE HAD DECIDED PRIOR TO DEPARTING TORONTO THAT IF NECESSARY, WE WOULD LAND INSTEAD IN PHN WHICH LOOKED ON THE MAP LIKE A GOOD HALFWAY POINT. INSTEAD OF LNDG IN PHN HOWEVER, WE DECIDED THAT IF ATC WOULD AGREE TO VECTOR US DIRECTLY TO YIP AND ALLOW US TO STAY AT ALT, WE WOULD CONTINUE TO OUR ORIGINAL DEST, KNOWING THAT WE WOULD LAND WITHOUT LEGAL RESERVES. I TOLD ATC THAT WE WERE HAVING A MINOR PROB WITH THE ACFT AND THAT ALTHOUGH WE WERE NOT DECLARING AN EMER AND WERE NOT REQUESTING PRIORITY HANDLING, WE WOULD APPRECIATE ANYTHING THEY COULD DO TO EXPEDITE OUR ARR INTO YIP. ON ARR AT YIP, THE ACFT HAD APPROX 20 MINS FUEL ON BOARD. WE ASKED THE COMPANY MECHS TO CHK THE FUEL QUANTITY GAUGES FOR ACCURACY, AND LOOK FOR A LEAK SOMEWHERE THAT WOULD HAVE CAUSED US TO LOSE SUCH A LARGE PORTION OF THE FUEL I HAD SEEN DELIVERED INTO THE ACFT. FINALLY, ONE OF THE MECHS COMMENTED THAT I HAD PROBABLY RECEIVED LITERS RATHER THAN GALLONS, AND I REALIZED THAT THIS WAS INDEED WHAT HAD HAPPENED. 1) I WAS COMPLETELY UNAWARE THAT CANADA FUELS ACFT IN LITERS NOT GALLONS. SEVERAL OF THE DECISIONS I MADE WERE BASED INCORRECTLY ON THE ASSUMPTION THAT THE REQUESTED AMOUNT OF FUEL HAD BEEN DELIVERED. BECAUSE I ACTUALLY WATCHED THE FUELER AND THE TRUCK METER DURING FUELING, I WAS CONVINCED THE ACFT HAD RECEIVED THE FUEL AND THAT MY QUANTITY GAUGE WAS WRONG. CONTRIBUTING TO THIS CONCLUSION WAS THE FACT THAT EARLIER IN THE DAY IN MEMPHIS WE ALSO HAD A LARGE SPLIT BTWN R AND L TANKS, EVEN THOUGH IN MEMPHIS THE TOTAL FUEL QUANTITY HAD BEEN CORRECT. IF I HAD NOT ACTUALLY SEEN THE FUELER PUMP THE GAS I WOULD NOT HAVE HESITATED TO QUESTION OUR FUEL LOAD. THE FUEL RECEIPT SHOWED 'LITERS DELIVERED' BUT I DID NOT NOTICE IT. THE SAFEST COURSE OF ACTION EVEN THOUGH I WAS 'SURE' I HAD ADEQUATE FUEL ON BOARD WOULD HAVE BEEN TO TAKE ON MORE FUEL. I HAVE NO IDEA WHY NEITHER I NOR MY COPLT INSISTED ON DOING THIS. 2) WHEN WE REALIZED WE WERE RUNNING LOW ON FUEL, AND THAT THE GAUGES HAD BEEN CORRECT, I OPTED TO PRESS ON TO OUR HOME ARPT RATHER THAN LNDG IMMEDIATELY. AT THAT POINT, EVEN THOUGH I KNEW WE WOULD LAND WITHOUT LEGAL RESERVES, I FELT CERTAIN WE COULD MAKE IT HOME. I THINK PART OF MY RELUCTANCE TO DIVERT WAS THAT I DIDN'T WANT TO GO THROUGH THE HASSLES (CUSTOMS NOTIFICATION) AND REPERCUSSIONS I FELT WOULD COME FROM LNDG SHORT OF THE DEST. I THINK I FELT I COULD GET THE ACFT SAFELY HOME, THE FACT THAT I HAD MADE SUCH A BAD DECISION LEAVING TORONTO WITHOUT ADEQUATE FUEL WOULD NOT BECOME AN ISSUE. ALSO, I STILL THOUGHT WE HAD A MAINT PROB WITH THE ACFT, AND FELT THAT IF I HAD LANDED IN PHN INSTEAD OF YIP, I WOULD HAVE TO GND THE ACFT THERE. IF ATC WOULD NOT HAVE COOPERATED, IF THE ARPT WAS IFR, OR IF I HAD ANY DOUBT OF MAKING IT SAFELY TO YIP, I WOULD HAVE DIVERTED IMMEDIATELY AND ACCEPTED THE CONSEQUENCES. 3) IN DISCUSSING THIS SIT AFTER THE FACT WE HAVE IDENTED A SEVERE PROB WITH BOTH MYSELF AND MY COPLT IN OUR CRM. ALTHOUGH WE CAREFULLY DISCUSSED OUR ACTIONS AND OPTIONS THROUGHOUT THE INCIDENT, WE BOTH FAILED TO PROPERLY PRACTICE GOOD CRM. APPARENTLY, THE COPLT WAS EXTREMELY UNCOMFORTABLE WITH SEVERAL OF MY DECISIONS, BUT NEVER STATED THAT. INSTEAD HE OFFERED SUGGESTIONS (SUCH AS SELECTING A DIVERSIONARY ARPT PRIOR TO DEPARTING TORONTO), AND HOPED I WOULD TAKE THE HINT. I, AS THE CAPT, KEPT SHOWING THE FO WHAT MY REASONING WAS, AND ESSENTIALLY KEPT 'SELLING' MY POINT OF VIEW, AND CONVINCING HIM TO GO ALONG WITH ME INSTEAD OF RE-THINKING MY DECISIONS. ALTHOUGH I KNEW HE WAS UNCOMFORTABLE, I KEPT SHOWING HIM THE LOGIC OF MY DECISIONS IN ORDER TO MAKE HIM MORE COMFORTABLE INSTEAD OF TAKING ANOTHER COURSE OF ACTION. 4) WHILE I DON'T REMEMBER BEING TIRED, I FEEL THAT FATIGUE AND 'GET-HOME-ITIS' HAVE TO HAVE CONTRIBUTED TO THE POOR DECISION MAKING IN THIS CASE. WE HAD BEEN ON DUTY SINCE XA30 PM THE PRIOR EVENING, AND IT WAS ALMOST XB30 AM AS WE LEFT TORONTO. WE HAD BEEN VERY BUSY AT OUR COMPANY LATELY, OFTEN FLYING 14 HR DUTY DAYS, AND GOING RIGHT BACK OUT AGAIN TO FLY IMMEDIATELY AFTER OUR REQUIRED REST PERIOD FOR SEVERAL DAYS IN A ROW. WE HAD ALSO BEEN WAITING IN THE AIRPLANE FOR ABOUT 1 HR FOR THE FUEL TRUCK. THE DECISION TO PRESS ON IN TORONTO INSTEAD OF GETTING MORE FUEL WAS SO UNCHARACTERISTICALLY FOOLISH, I CAN ONLY GUESS THAT FATIGUE HAD SOMETHING TO DO WITH IT. AS FOR CORRECTIVE ACTION, I AM NOW AWARE THAT CANADA FUELS IN LITERS NOT GALLONS, AND WILL BE MORE AWARE OF THAT FACT IN THE FUTURE IN ANY FOREIGN COUNTRY I FLY TO. BOTH MYSELF AND MY COPLT HAVE LEARNED THAT WE NEED TO WORK ON OUR CRM. HE SHOULD HAVE VOICED HIS CONCERNS INSTEAD OF HINTING AND SHOULD HAVE COMMUNICATED HIS DISCOMFORT INSTEAD OF GOING ALONG WITH ME. I SHOULD HAVE BEEN MORE AWARE OF HIS RELUCTANCE EVEN IF HE DIDN'T STATE IT OUTRIGHT, AND SHOULD HAVE REALIZED AT SOME POINT IN MY 'SALES PITCH' THAT I NEEDED TO RETHINK MY DECISION.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.