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Factual Information

Summary

At about 1930 Western Standard Time1 on 26 January 2001, a Cessna 310R aircraft, VH-HCP, departed Kiwirrkurra, Western Australia (WA), for Newman. The flight was conducted at night under the visual flight rules (VFR), with one pilot and three passengers on board. The aircraft was operated by the Air Support Unit (ASU) of the WA Police Service and had been used to transport police officers from Newman to Kiwirrkurra earlier that day.

The aircraft arrived in the circuit area at Newman at about 2150 for a landing on runway 23. Witnesses at the aerodrome heard the engines start to 'cough and splutter'. Soon after, the aircraft collided with the ground about 3 km to the east of Newman aerodrome. The four occupants sustained fatal injuries. Impact forces destroyed the aircraft.

The investigation determined that both of the aircraft's engines failed due to fuel starvation,2 prior to impact with the ground. There was no evidence of a technical malfunction or of an in-flight fuel leak. From the information available, the investigation calculated that the aircraft probably had about 165 L of useable fuel at impact. Approximately 30 L of fuel was recovered from the aircraft's auxiliary fuel tanks and it was probable that fuel had leaked from these tanks post-impact.

The investigation identified a number of factors that had contributed to the circumstances of the accident. These factors included operational events on the night of the accident, local conditions associated with the circumstances of the operational events, the defences that were used to manage risk, and organisational conditions that influenced the effectiveness of the defences.

Operational events and local conditions

The investigation identified a number of deficiencies associated with the pilot's pre-flight preparation and conduct of the flight. There was no evidence that he had obtained a weather forecast, considered the need for extra fuel, or submitted the appropriate flight notification and he had exceeded the maximum duty period permitted by the Civil Aviation Safety Authority (CASA) under Civil Aviation Order 48. Also, the flight was not operated in accordance with required procedures for VFR flights conducted at night, with respect to contingencies for runway lighting and provision for flight to an alternate aerodrome. The investigation concluded that these factors suggested that the pilot had probably not identified, or fully considered, the hazards associated with the flight. A number of physiological factors such as fatigue, dehydration, and a lack of recent nutrition could also have affected his performance. The pilot was probably experiencing self-imposed pressure to conduct the flight.

The fuel starvation of the engines was probably the result of inadequate techniques used by the pilot to monitor and manage the consumption of fuel from the aircraft's fuel tanks. This had resulted in a low quantity of fuel in the main fuel tanks at the time the engines failed. The investigation could not determine the sequence of events that led to the low quantity of fuel in the main tanks. It was possible that the pilot had inadvertently omitted to use the auxiliary tanks, had used the auxiliary tanks for an unusually short period of time, or made some other type of error with the tank selections during the flight. Regardless of what fuel tank selections were made during the flight, the pilot had probably not detected the critically low quantity of fuel in the main tanks towards the end of the flight. The investigation could not find any evidence that the pilot had used structured techniques to monitor the quantity of fuel consumed from the aircraft's tanks during the flight. This could have affected his ability to successfully detect and resolve abnormal indications from the aircraft's fuel gauges.

The pilot experienced a difficult set of circumstances in which to respond to the initial and subsequent engine failure. Those circumstances included a lack of significant external visual reference due to the dark night conditions, the limited height available at circuit altitude and the pilot's skill level in handling emergency situations in multi-engine aircraft. He did not maintain control of the aircraft following the engine failures.

The pilot held a commercial pilot (aeroplane) licence and was rated to fly single-engine aircraft at night under the VFR. He did not hold a valid rating to fly multi-engine aircraft at night, although he probably thought that he had been issued with such a rating following a flight test conducted by the ASU chief pilot. However, the chief pilot was not authorised by CASA to conduct flight tests to issue night VFR ratings. The investigation could not find any objective evidence to indicate that the occurrence pilot had received recent training to control a multi-engine aircraft solely by reference to the aircraft flight instruments following a simulated engine failure, or that this ability had been tested prior to, or after the issue of, the (invalid) multi-engine night VFR rating.

Defences and organisational conditions

The investigation concluded that the processes used by the ASU for training in, and supervision of, fuel planning and fuel management were deficient. This probably contributed to the occurrence pilot not using structured procedures and techniques that could have provided him with a greater level of awareness of his fuel situation during the flight.

Deficiencies were also found with the ASU training and checking of night operations. Pilots did not receive recurrent checking of their performance during night operations. The ASU had not fully recognised the risks of remote area night operations and did not have effective defences to manage those risks.

The ASU chief pilot had been provided with minimal training, guidance and professional development to effectively perform his duties. His performance in several safety critical areas was not monitored and resulted in a series of failures in the overall system of safety management at the ASU. Senior management of the WA Police Service assumed that the regulatory relationship between the ASU and CASA provided adequate assurance that the ASU's operations were conducted to an appropriate standard. However, CASA prioritised its surveillance activities, utilising available resources to achieve surveillance targets for operations carrying fare-paying passengers. Organisations holding an aerial work Air Operator's Certificate (AOC), such as the ASU, were allocated a lower priority when planning surveillance tasks and therefore CASA had not performed any significant assessment of the ASU's fixed-wing operation during recent years.

A number of the ASU's safety defences exceeded minimum regulatory requirements. However, the overall safety management system did not have the capacity to ensure the safety of operations in the wide range of circumstances that could reasonably be anticipated. Insufficient management processes existed to ensure that adequate defences were in place at the operational level to provide an assurance of flight safety.

The WA Police Service provided limited guidance for the ASU to develop safety management processes. The ASU management was expected to develop such processes, and a heavy emphasis was placed on the ASU chief pilot to ensure the safety of flight operations. Although he was a key person within the organisation with defined legal responsibilities, he had not been adequately prepared for this role, and the WA Police Service had no procedures to ensure that the chief pilot was supervising operations to an appropriate safety standard. Many of the deficiencies detected with the ASU's system of safety management had existed for many years, but the WA Police Service did not have a system to identify safety deficiencies in operational areas.

As a result of this accident, the ASU implemented a number of changes to the conduct of its operations. These included: the introduction of a new operations manual; a new training and checking manual; revised procedures for management of fuel by the ASU's pilots; appointment of a safety manager within the ASU; implementation of a hazard identification and communication program; and introduction of procedures to supervise remotely-based pilots. The WA Police Service also formally recognised the chief pilot position in the organisational structure of the service and implemented a reform process to improve pilot and crew selections, training, flight risk management, fatigue management, professionalism, external crosschecking and validation of the ASU systems against industry best practice.

Other issues

At the time of the accident, the relevant aviation regulations permitted flight at night under the VFR at times when pilots may have had insufficient external visual reference to control the aircraft using external visual cues. Under such conditions, the pilot would have been required to control the aircraft using the flight instruments. However, the training and currency requirements for VFR operations at night placed minimal emphasis on flight under such conditions. There was no formal advisory material linked to these requirements to help pilots identify higher risk situations or otherwise encouraging the use of various risk mitigation strategies.

The process used by CASA to approve the appointment of the ASU chief pilot did not detect his (or the operator's) limited knowledge of system safety concepts, nor did it provide any assurance that he understood the extent of his role and responsibilities as chief pilot. That also extended to the manner by which the chief pilot received his CASA approval as a training and checking pilot.

Some of the deficiencies associated with the ASU's procedures and management processes may have been able to be detected during the completion of a CASA periodic inspection. The investigation could not determine why those deficiencies were not detected during earlier periodic inspections, during reviews of documentation associated with checklist completion for the reissue of an AOC, and at other times CASA staff had contact with the ASU.

CASA has recently modified its surveillance planning to ensure that all operators are subject to a recertification audit prior to the reissue of an AOC. CASA is also progressively working on its capacity to identify organisations requiring additional surveillance activity on the basis of risk.

CASA has proposed a number of regulatory changes in the area of General Operating and Flight Rules that relate to fuel planning and fuel management.

While acknowledging the significant safety action underway, the ATSB has issued three additional recommendations concurrently with the release of this report. The recommendations cover: the provisions for the disposition of fuel reserves in fuel tanks to be used during the approach and landing; operational requirements and guidance material for pilots conducting VFR flight in dark night conditions; and required qualifications and/or competencies for chief pilots, with particular reference to management and system safety issues.


1 Australian Western Standard Time is UTC +8 hours.

2 Fuel starvation refers to an event where fuel is not being supplied to the engines, but useable fuel is available in at least one of the aircraft's fuel tanks.

 
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