On 11 August 2003, a twin-engine Cessna 404 'Titan' aircraft (VH-ANV) crashed into scrub land near Jandakot airport, WA, following the failure of the right engine immediately after takeoff. The ATSB investigation (200303579) found that the engine failure had been precipitated by the seizure of an engine-driven fuel pump (EDFP), which had been previously repaired using an inappropriate (non-original) material to replace the pump shaft sleeve bearing. That repair had been designed and approved by a person authorised under the CivilAviation Regulations (1988) part 35 (CAR 35).
In April 2005, after the discovery of another CAR 35 approved pump repair that substituted the original pump bearing material with an unsuitable alternative, the ATSB commenced an investigation into the circumstances surrounding the material selection processes and the factors contributing to the inappropriate material selection. Concurrent with the ATSB investigation, an inquest conducted by the WA State Coroner examined the circumstances of the VH-ANV accident, including the pump bearing material issues.
The ATSB investigation found that in both instances, the authorised persons that prepared the Engineering Orders (EO) for the EDFP repairs, had done so without specific knowledge of the differences between the original and newly selected materials in regard to their bearing properties, and the precise conditions under which the fuel pump bearings operated.
Safety action resulting from the investigation of these issues included the publication of the VH-ANV investigation findings in various industry journals and educational materials. The findings and recommendations of the VH-ANV coronial inquest, and the industry communications released by the Civil Aviation Safety Authority (CASA) acted to further promote understanding of the material selection deficiencies.
|Date:||08 April 2005||Investigation status:||Completed|
|Release date:||23 January 2008||Occurrence class:||Technical|
|Report status:||Final||Occurrence category:||Technical Analysis|
|Highest injury level:||None|
|Aircraft manufacturer||Cessna Aircraft Company|
|Type of operation||Air Transport Low Capacity|