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Factual Information

Summary

The pilot of a Cessna 210 Centurion was tasked to fly three passengers from Kalgoorlie WA to Rawlinna WA and return.

The aircraft departed Kalgoorlie at 0804 Western Standard Time for Rawlina with the flight proceeding without incident. The trip fuel log showed that the pilot believed that the aircraft arrived in Rawlinna with approximately 106L remaining in the left tank and 130L remaining in the right tank. The aircraft was not refuelled at Rawlinna.

Two passengers watched the pilot prepare for the return journey from Rawlinna. They reported that the pilot appeared to do a walk around the aircraft and one passenger stated that although he saw the pilot `check things at the front, wingtips and tail', the pilot did not check the fuel tanks in the wings. At approximately 1250, the flight departed for Kalgoorlie. One of the passengers recalled that, shortly after reaching a cruise altitude of about 4,000ft, the pilot appeared to become agitated and was checking something on the floor between the seats. This concerned the passenger, but after a few minutes, the pilot settled down and the passenger assumed that whatever had been a concern, was resolved. The fuel selector is located on the floor between the two front seats.

One passenger with recollection of the remainder of the flight from Rawlinna, stated that it appeared routine up until the engine lost power while the aircraft was approaching Kalgoorlie. (Due to the serious nature of the head injuries sustained in the accident by all of the passengers, their recollections of the flight prior to the engine power loss were very fragmented.)

At approximately 1413, the pilot was heard to broadcast a distress call including the aircraft altitude of 2,000 ft above sea level and his intention to land on a road. During the landing attempt, the passenger in the right front seat observed a car appear in the landing path. The passenger reports of what occurred after the car appeared were consistent with the pilot attempting to climb the aircraft to avoid the car and subsequently losing control of the aircraft during the manoeuvre.

The driver of the car and his wife saw the aircraft pass silently overhead as it crossed the road in a southerly direction. When it impacted the ground, the car driver's wife said that it appeared to `really bury in' before it was obscured by a large cloud of dust.

The driver immediately called emergency services and then he and his wife attempted to render assistance to the occupants. The pilot was fatally injured while the passengers were seriously injured.

Wreckage information

The aircraft impacted the ground in a left wing low, nose-down attitude. Examination of the aircraft found the left and right fuel tanks intact, but the fuel system plumbing was disrupted by cabin distortion at the fuel tank selector valve under the floor. The fuel line to the firewall mounted filter strainer and engine was broken and the strainer was destroyed during the accident impact sequence. The forward door pillar had been severed on the right side of the aircraft by hydraulic cutters used during the rescue effort to free the trapped front seat passenger. The examination of the fuel tank selector revealed that the right fuel tank was selected at impact.

Fuel had poured on to the right front seat occupant during the rescue and had continued for a considerable amount of time after the accident. No fuel remained in the right tank when it was examined by the investigation team on site. The rescuers said that they had not observed fuel to leak from the left wing onto the ground at any time. The aircraft's left wing low attitude uncovered the engine fuel supply lines at the inboard end of the tank and, as a result prevented the remaining left tank contents escaping through the damaged connections to the fuel selector. Less than half a litre of clean fuel remained in the outboard section (lowest point) of the left tank compartment and was considered to approximate the unusable amount for the tank. A sample of the Avgas, which was normal green colour, was taken from the aircraft and inspected at the accident site. It was free of any water or particles in suspension and visible contaminants. The fuel uplift for the flight was from the Kalgoorlie aerodrome. This fuel supply was tested by the supplier and found to be within correct specification.

The left wing vent line was also clear of the remaining contents and did not appear to have been capable of allowing the remaining contents to drain off through the left wing tip vent due to the syphon effect. The fuel contractor's log showed that there were multiple deliveries from the same batch of fuel to other aircraft operating from Kalgoorlie airport coincident with the delivery to VH-LMX. The bureau found no reports of fuel related problems with any of these other aircraft.

The fuel system components were bench tested and found to be capable of normal operation within the manufacturer's parameters. The wreckage, engine and component examinations found no evidence of pre-existing mechanical defects with the aircraft or its systems, that would have prevented normal operation of the aircraft prior to the accident.

Fuel pump switch

The auxiliary fuel pump switch is a two-segment split rocker type mechanism. The right half was colour-coded yellow and the left half red. The yellow half was marked START, with the upper position as ON and was used for normal start and some minor vapour purging if required. It was usually selected OFF for normal flight. In the event of an engine driven fuel pump failure in cruise flight, the yellow switch selected to ON should have provided, through a micro-switch arrangement, sufficient fuel for normal engine operation. The red half of the switch was marked EMERG (emergency) with its upper position marked as HI. This red switch was used in the event of an engine driven fuel pump failure during takeoff or high power operation and also extreme vapour purging. When the auxiliary fuel pump switch was removed and examined the yellow segment was found in the ON position.

A fuel dipstick with graduated markings on it was found in the baggage compartment of the aircraft. It was marked C210M VH-WXC and had the following graduations: LEFT FULL, 140, 100, 60, 30 with identical graduations and the word RIGHT on the reverse side of the stick. A check of the type certificate data sheet revealed that the C210N (accident aircraft) was fitted with identical type and capacity fuel tanks to the C210M.

Emergency locator transmitter

The aircraft was fitted with an emergency locator transmitter that activated upon impact. The transmission was received and logged by the Australian search and rescue organisation (AUSSAR) for 2hrs 39 mins before local police disabled the transmitter.

Pilot information

The pilot held a valid Australian commercial pilot licence and command instrument rating. He held a valid Class 1 medical certificate and did not require vision correction while operating an aircraft. At the time of the accident the pilot had accrued a total of 1,087 hours flying experience with 317.5 hours on the Cessna 210. From interviews and post mortem results, no evidence was found that the pilot had any personal or medical problems that may have adversely impinged on his ability to conduct the flight.

Survival

The nose-down, left wing low attitude of the aircraft as it impacted the ground exposed the left front seat occupant (the pilot) to the full force of the impact.

The passengers sustained numerous serious injuries in the form of fractures to legs, upper bodies and heads as well as injuries to internal organs. The leg injuries probably occurred when the floor was forced in an upward direction during the impact sequence. The floor movement also released the anchor points for the front seats. The middle row right seat remained fixed to its mounts. The middle left seat remained fixed by its rear mounts and forward left mount but with the front right mount partially released. There were no upper body restraint systems fitted to the passenger seat row positions in the aircraft, nor were any required to be. The upper body and head injuries sustained by all occupants were probably due to upper torso flailing contact with interior structure and objects. The front seat positions were fitted with upper body restraints. The effectiveness of the front seat restraint systems was compromised by the loss of integrity of the seat to floor attachments. The rearward movement of the engine firewall during the impact sequence may also have reduced the front seat survival space between front seat occupants and control panel structures; which would have increased exposure to injury.

Weather

The weather forecast for the day was for fine conditions, but with thunderstorm activity expected in the Kalgoorlie area during the afternoon after the flight. Other pilots reported experiencing some heavy turbulence in the area during the day and the operator's Chief Pilot remarked it was, `the first really rough day of the season'. The passengers recalled that, for the portions of the flight that they could remember, there was some turbulence but remarked that it was not unusually rough.

Aircraft fuelling

The afternoon before the charter flight, the aircraft operator requested the fuel contractor to fill the aircraft tanks (capacity 160L in each of two tanks) `to the tabs', which equated to a fuel quantity of approximately 120L in each fuel tank. The fuel request form was normally faxed to the fuel depot during the afternoon, but as no request had been received by the time he was due to commence fuelling tasks, the fuel contractor obtained the request sheet by walking to the aircraft operator's office and retrieving the original. The contractor noted that the sheet had been amended by the use of white-out correction fluid and that the original request entered had been for full tanks. It could not be positively determined if the pilot had sighted this fuel quantity request sheet.

Company pre-flight briefing

Some months after the accident, a director of the company stated that he spoke to the pilot in the afternoon prior to the accident flight. This conversation covered the task briefing for the following day and included the fuel load as being `to the tabs'. If this was so, the weight and balance calculations made by the pilot for the flight, in which a `full fuel' quantity was used and showed that the aircraft was close to maximum take off weight, did not reflect any knowledge that he had received the `fill to tabs' fuel information. The director could not confirm whether the pilot assimilated this information at the time he talked to him.

Aircraft service history

The aircraft had been maintained in accordance with the relevant Civil Aviation Regulations and Orders. The aircraft had a valid maintenance release at the time of the accident with no maintenance overdue. Because a fuel quantity system calibration was required by the Civil Aviation Safety Authority (CASA) every three years as part of an airworthiness directive (AD), a calibration had been carried out six months prior to the accident in accordance with the AD. The gauge calibration results recorded in the aircraft logbook were as follows:

Left  10/46, 20/83, 30/117, 40/167, F/169 (Gallons/Litres)
Right 10/38, 20/65, 30/100, 40/145, F/164 (Gallons/Litres)

The aircraft fuel gauges, calibrated in US Gallons, were within the required parameters but the quantities differed between the left and right tanks for a given scale marking. This was compensated for by having a calibration correction card fitted to the aircraft. The calibration recordings in the logbook did not include a value for E (empty). However the calibration card fitted to the aircraft stated that for E indication on the gauge, the tanks were to be read as empty.

A review of the aircraft's history revealed that, when being operated by its previous owner on the east coast, it had been involved in a similar accident in 1995 when it was force landed due to engine power loss. The aircraft had also taken off with the fuel tanks filled `to the tabs', and on that occasion it was estimated that the pilot had operated the aircraft for approximately 1 hour and 40 minutes when the engine lost power. The left fuel tank was used for the entire flight and when examined at the accident site, it was found to be empty.

Flight trip log

A company trip fuel log for the flight was found at the accident site. This log was being used by the pilot to record flight times and fuel usage from each tank for the flight. It had the following annotations:

Place Time Left Right
KG 0804 160 160

34 130 160

04 130 130
RAW 0928 106 130
RAW 1250 106 130

05 91 130

1345 91 90

The trip fuel log noted that the fuel tanks contained 160L in each tank on departure from Kalgoorlie.

The takeoff from Kalgoorlie had been conducted using fuel from the left tank. The trip fuel log indicated that the aircraft had consumed 54 litres from the left tank and 30 litres from the right tank during the flight to Rawlina. Additionally the log indicated that the pilot elected to remain on the left tank for the taxi, pre-takeoff checks, takeoff and departure from Rawlinna thereby carrying out both takeoffs using fuel from the left tank. The pilot recorded an initial use of 15L from the left tank on departure from Rawlinna, followed by 40L from the right. At 13:45 WST he changed the selection to the left tank. About 28 minutes later, the engine lost power.

Pilots Operating Handbook (POH)

The aircraft was fitted with a placard that provided information in the form of a checklist in the event of major fuel flow fluctuations and/or engine power surges. Additionally the POH provided expanded procedures for inflight engine restarts and excessive fuel vapour in the fuel system. The POH also noted that if the propeller is windmilling, the engine will start automatically within a few seconds. If the propeller has stopped (possible at lower speeds), turn the ignition switch to START, advance the throttle slowly from idle, and (at higher altitudes) lean mixture from full rich.

The POH went on to indicate that with fuel quantities of less than a quarter tank, prolonged uncoordinated turns or slips should be avoided as it might uncover the fuel tank supply outlets and starve the engine of fuel.

Engine out glide distance

The MAYDAY transmission made by the pilot placed the aircraft at a height of 800 ft above ground level. This height, according to the Maximum Glide graph in the POH, equated to approximately 1.2 NM, or approximately one minute of glide time from the time at which the engine lost power to the impact point.

 
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