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Analysis

Summary

Evidence indicated that the engines had stopped because of fuel exhaustion.

In order to maximise payloads the aircraft was normally operated with the minimum fuel sufficient for safe flight. Consequently, the fuel tanks would have rarely been filled to capacity. As filling the fuel tanks to capacity provided one of the only opportunities to accurately determine a datum for the assessment of fuel quantity, any subsequent inaccuracies in the system of assessing fuel quantity would have compounded over extended periods. As most of the pilot's previous flying experience had not involved working in situations where it was necessary to carefully balance the requirements of payload against fuel, it is possible that he did not recognise the critical need to carefully monitor such aspects of the operation.

There were two systems available to a pilot to monitor fuel quantity - a fuel quantity indicator and a fuel log. The fuel quantities as determined by each system should have been in agreement. During the accident flight, however, the pilot had covered the fuel gauge due to intermittent and unreliable fuel indications, which made one system unusable. In addition, the fuel-log system was not being applied with rigour and did not provide an accurate indication of the actual fuel quantity. This had masked any opportunity to reveal differences in estimated and actual consumption rates, when compared with the fuel gauge. As a result, at the time of the occurrence the aircraft had substantially less fuel on board than the pilot believed to be the case.

CASA had recently assessed the pilot as competent to act as chief pilot. Although he met all the regulatory requirements to fulfil that role, he had little experience in managing flight operations to ensure regulatory compliance. The process of approval for the position of chief pilot did not appear to adequately assess his capabilities to control and maintain a consistent, safe system of flight operations. The process adequately addressed the candidate's knowledge of the regulatory requirements, but was insufficient to adequately assess managerial ability. Although the organisation was approved to conduct fare-paying passenger flights, the management structure and expertise of the chief pilot did not provide for effective oversight of the operational aspects of those activities. The rear left seat passenger was thrown forward into the front right seat by impact forces because the seat-belt restraint was probably not secure at the time of impact, due to the unusual amount of force required to secure it correctly. This may have given the impression that the harness was locked when in fact it was not securely fastened.

FINDINGS

  1. The pilot was correctly licensed and qualified to operate the flight as a VFR charter operation.
  2. The aircraft was dispatched with an unusable fuel quantity indicator.
  3. The right engine fuel control unit was worn and allowed additional fuel through the system, increasing fuel consumption by approximately 6 L/hr.
  4. Inappropriate fuel consumption rates were used for flight planning.
  5. The aircraft fuel log contained inaccuracies that resulted in a substantial underestimation of the total fuel used.
  6. At the time of the occurrence, there was no useable fuel in the aircraft fuel system.
  7. Although the pilot met the Civil Aviation Safety Authority criteria to fulfil his role as chief pilot, he did not have the expertise to effectively ensure the safety of company flight operations.
 
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