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First defence against errors and omissions

  • Pilots are reminded to be diligent in the performance of checklist items during all stages of flight as they are there to capture errors made before and during flight. 
  • Checklists are the most readily available way to manage risks of errors and omissions.

The ATSB is urging pilots to be diligent in the performance of checklist items during all stages of flight. This reminder follows an incident where a Piper Seneca experienced fuel starvation while cruising at 9,000 ft above sea level. 

On 31 August 2012, the aircraft departed Hobart Airport for Bankstown on a private flight. At about 19 km south of Nowra, the pilot (who was the only person on board) heard a bang and the left engine stopped with the right engine stopping shortly after. The pilot immediately feathered the propellers, declared a PAN and started looking for a suitable area to land. He proceeded through the memory items on the emergency checklist. While performing the emergency checklist, the pilot discovered that the right fuel selector was in the cross-feed position and the left fuel tank had run out of fuel. He repositioned the fuel selectors and restarted both engines.

At the time of the engine restart, the aircraft had descended to 4,000 ft. The pilot advised air traffic control that both engines were now running and that he would continue to Bankstown as planned.

On landing at Bankstown, the aircraft had a significant lateral imbalance, as the left wing tank was empty and the right wing tank was almost full. As a result, the aircraft departed the runway after landing. The pilot regained control and the aircraft taxied to the parking area without further incident. The aircraft was not damaged and the pilot was not injured.

The pilot had been accustomed to being assisted on flights by his wife, who would hold the checklist and read out the items. On this flight, however, she was not with him. Checklists are the most readily available means of risk management against errors and omissions.

Read the investigation report, AO-2012-112.

 

 
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Last update 15 January 2013