Sequence of events
At about 1659 Central Standard Time, on 29 November 2004, the right engine of an Embraer-Empresa Brasileira de Aeronutica, E110-P1 Banderiante, failed during the landing approach. The aircraft, registered VH-BWC, was being operated on a charter flight from Bathurst Island to Darwin, NT, with two crew1 and 18 passengers.
The air traffic controller cleared the pilot to track via Lee Point for a right base for runway 29. The pilot reported that during the approach, about 6 NM from Darwin, he noticed that the right fuel pump warning light was flashing. Shortly after, the left fuel pump light flashed and he noticed that the fuel gauges were indicating empty. The pilot informed the controller that an engine was shutting down and requested and received a clearance to land on runway 18, which had about 5 kts downwind component. During the landing roll, the left engine also failed and both main landing gear tyres were damaged due to excessive brake application. There was no other damage and none of the occupants were injured.
The aircraft's fuel tanks were drained during the investigation, and were each found to contain about 3L of fuel. The aircraft's trip record sheet indicated that the fuel remaining prior to the last refuelling was 620 lbs and that 180 lbs had been added prior to the first flight of the day.2
The planned departure time from Darwin for the flight to Bathurst Island was 1600. At about 1500, the pilot ordered 450 lbs of fuel for the aircraft. The pilot held senior management responsibilities in the company and had been heavily distracted by those duties until after the planned departure time. He subsequently departed for Bathurst Island at 1610. The refueller was delayed and did not arrive at the operator's apron until after the aircraft had departed.
The pilot subsequently did not check the fuel quantity prior to departing from Darwin for Bathurst Island, and assumed that it had been refuelled. At the time of the incident the total fuel consumed since the last refuelling was 835 lbs.
The investigation found that the pilot in command omitted vital fuel quantity checks prior to departure from Darwin and again at Bathurst Island. The operator did not have a procedure to cross reference and verify that the required quantity of fuel had been added. The investigation determined that the lack of fuel verification procedures to confirm that the required fuel had been added, and the pilot's attention being diverted to management tasks, together contributed to this fuel exhaustion occurrence. The Bureau classified the occurrence as a serious incident due to the potential for a much worse outcome had the exhaustion occurred any earlier.
- The crew comprised a pilot in command and a flight attendant.
- The Bandeirante's fuel system records fuel quantity and usage in pounds (lbs). Fuel is ordered in litres. One litre of Jet A-1 fuel normally weighs 1.72 lbs, depending on the density of the fuel on the day.
On 2 December 2004, the operator advised that as a result of this serious incident, the following changes had been implemented:
- Bandeirante flights operated by the company will be restricted to two-pilot operations
- A company memo will be issued immediately and the operations manual amended to reflect the company's fuel verification process, which will require that verification must be obtained by cross checking the amount of fuel on the fuel docket with the amount of fuel on board the aircraft. If no receipt is found it will be assumed that no refuelling has taken place
- The pilot's senior management and flying activities are being addressed.
On 17 December 2004 the operator advised that it had implemented, or was in the process of implementing, the following safety actions:
4.1.1 Informal communications between the company and the refuelling service provider.
4.1.2 Safety Actions
220.127.116.11 The operations manual will be amended to require direct, flight crew supervision of aircraft fuelling whenever practical. Direct supervision means being present throughout the fuel uplift, receiving the delivery docket in person and confirming the type of fuel, the fuel quantity and the distribution between fuel tanks.
18.104.22.168 The operations manual will be amended to require flight crews to confirm receipt of the delivery docket before departure and crosscheck expected fuel on board by a second independent means. Eg: Fuel uplifted crosschecked by visual inspection in tank or aircraft fuel gauges.
22.214.171.124 A memo has been issued implementing the requirements of 126.96.36.199, effective until amendments are included in the operations manual.
4.1.1 [4.2.1] Conflict between responsibilities for a single person acting in multiple roles of management, line pilot and aircraft owner.
4.2.2 Safety Actions
188.8.131.52 The company has permanently restricted the office of Chief Executive Officer to only participate in formal, two pilot flight operations. (Two pilot operations do not include the operation of single pilot aircraft with a safety pilot, endorsed on type or otherwise.)
184.108.40.206 Aircraft owners who also participate in flight operations must employ a maintenance controller to oversee maintenance allocations and to that end, company management should interact only with the maintenance controller about those aircraft.
220.127.116.11 The company requires aircraft owners to relinquish any active participation in the overseeing of their aircraft during all periods when the owners are rostered for flight operations.
18.104.22.168 Where an aircraft owner also holds a management position within the company that could see them interacting with flying staff about those aircraft, another senior management staff member (preferably the chief pilot) must be included in any such interaction.
4.3.1 Some Bandeirante pilots were operating under 2 different procedures, single and two pilot SOP's.
4.3.2 Safety Actions
22.214.171.124 The company has ceased all single pilot operations in the Bandeirante and removed the single pilot SOP's from its operations manual. The Bandeirante will be operated under the companies 2 pilot SOP's only.
126.96.36.199 All crew members operating under the company 2 pilot SOP's for the 1st time, will be required to complete a minimum of 10 sectors as co-pilot or ICUS using those SOP's, before acting as PIC in 2 crew operations.
188.8.131.52 As a part of retraining, the requirements of 184.108.40.206 will apply to the PIC in the incident, when reintroduced to flight operations.
220.127.116.11 The operations manual will be amended to include 18.104.22.168, and the policy will be transferred to the company's Check and Training Manual (currently being written) when it is approved and incorporated into the operations manual.
4.4.1 Inadequate Bandeirante checklist requirements regarding fuel quantity.
4.4.2 Safety Actions
22.214.171.124 The company has ceased all single pilot operations in the Bandeirante and removed the single pilot SOP's from its operations manual. The Bandeirante will be operated under the companies 2 pilot SOP's only.
126.96.36.199 The company's SOP's for the Bandeirante, are being amended to include a crosscheck of actual fuel on board with full required for flight as a part of the pre-takeoff briefing by the handling pilot.
188.8.131.52 The chief pilot held a briefing session with current Bandeirante crewmembers, reviewing the BWC incident and implemented changes, including those in 184.108.40.206.
4.5.1 Operations Manager and support staff have insufficient understanding of pilots' duties and responsibilities during pre-flight and flight turnaround periods.
4.5.2 Safety Actions
220.127.116.11 The company is amending its operations manual to require flight crews sign on a minimum of 1 hour prior to departure.
18.104.22.168 Operations are to allow a minimum of 45 minutes between flights when rostering turnarounds in Darwin, and a minimum of 1 hour between flights that require a flight crew to change aircraft and/or aircraft type.
22.214.171.124 The company is preparing theory course material covering basic aeronautical knowledge appropriate to the company's fleet and type of operation, which the operations manager will be required to complete. The course is also to include the requirements of CAO 48 flight and duty time limitations. The course will be assessable and able to be audited.
126.96.36.199 The company is preparing appropriate theory course material covering the company's fleet and operations, which check-in and support staff will be required to complete. The course will be assessable and able to be audited.
188.8.131.52 The company is progressively requiring the operations manager, and all flying operations support staff to read the company's' operations manual with an appropriate pilot designated to assist in its understanding. Operations staff must sign that they have read, understood and will comply with its contents.'
|Date:||29 November 2004||Investigation status:||Completed|
|Time:||1659 hours CST|
|Location:||11 km N Darwin, Aero.|
|State:||Northern Territory||Occurrence type:||Fuel exhaustion|
|Release date:||24 December 2004||Occurrence category:||Serious Incident|
|Report status:||Final||Highest injury level:||None|
|Aircraft manufacturer||Embraer-Empresa Brasileira De Aeronautica|
|Type of operation||Charter|
|Damage to aircraft||Minor|
|Departure point||Bathurst Island, NT|
|Departure time||1645 hours CST|
|Role||Class of licence||Hours on type||Hours total|