Aviation safety investigations & reports

Fuel starvation - Jundee Airstrip, WA, 26 June 2007, VH-XUE, Empresa Brasileira de Aeronautics S.A., EMB-120ER

Investigation number:
AO-2007-017
Status: Completed
Investigation completed

Summary

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On 26 June 2007 at 0639 Western Standard Time, an Empresa Brasileira de Aeronáutica S.A. EMB-120ER aircraft, registered VH-XUE, departed Perth, WA on a contracted passenger charter flight to Jundee Airstrip. There were two pilots, one flight attendant, and 28 passengers on the aircraft.

While passing through 400 ft above ground level on final approach to Jundee Airstrip, with flaps 45 set, the aircraft drifted left of the runway centreline. When a go-around was initiated, the aircraft aggressively rolled and yawed left, causing the crew control difficulties. The crew did not immediately complete the go-around procedures. Normal aircraft control was regained when the landing gear was retracted about 3 minutes later.

The left engine had sustained a total power loss following fuel starvation, because the left fuel tank was empty. The investigation identified safety factors associated with the fuel quantity indicating system, the ability of the crew to recognise the left engine power loss, and their performance during the go-around. There were clear indications that the operator's fuel quantity measurement procedures and practices were not sufficiently robust to ensure that a quantity indication error was detected. The failure of that risk control provided the opportunity for other safety barriers involving both the recognition of, and the crew's response to, the power loss, to be tested. Organisational safety factors involving regulatory guidance, the operator's procedures, and flight crew practices were identified in those two areas. The operator introduced revised procedures for measuring fuel quantity and the Civil Aviation Safety Authority (CASA) initiated a project to amend the guidance to provide better clarity and emphasis.

The crew's endorsement and other training did not include simulator training and did not adequately prepare them for the event. There was no EMB-120 flight simulator facility in Australia and no Australian regulatory requirement for simulator training. In March 2009, an EMB-120 flight simulator came into operation in Melbourne, Vic. A workshop and discussion forum was conducted on 27 to 28 April 2009 for Australian Embraer 120 aircraft operators. All those operators were expected to commence utilising the simulator for flight crew endorsement training following that workshop.

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Interim Factual

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Interim Factual report released 20 March 2009

While passing through 400 ft above ground level on final approach, the aircraft drifted left of the runway centreline. The crew decided to go around and on applying power, the aircraft rolled and yawed left, resulting in significant control difficulties for the crew. After the crew regained control of the aircraft, they realised that the left engine had stopped. The crew completed the emergency checks, transmitted a PAN call and diverted to Wiluna. It was later determined that the left fuel tank was empty and that the left engine had sustained a total power loss from fuel starvation.

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Preliminary

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Preliminary report released 14 September 2007

While passing through 400 ft above ground level on final approach, the aircraft began an uncommanded yaw to the left. The crew decided to go around and on application of power, realised that the left engine had failed. The crew completed the emergency checks, transmitted a PAN call and diverted to Wiluna for a safe landing.

 

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General details
Date: 26 June 2007   Investigation status: Completed  
Time: 0830 WST   Investigation level: Complex - click for an explanation of investigation levels  
Location   (show map): Jundee Aerodrome    
State: Western Australia   Occurrence type: Fuel starvation  
Release date: 08 July 2009   Occurrence class: Operational  
Report status: Final   Occurrence category: Serious Incident  
  Highest injury level: None  

Aircraft details

Aircraft details
Aircraft manufacturer Embraer-Empresa Brasileira De Aeronautica  
Aircraft model EMB-120  
Aircraft registration VH-XUE  
Serial number 120 115  
Type of operation Charter  
Damage to aircraft Nil  
Departure point Perth, WA  
Destination Jundee, WA  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command ATPL 540 3010
Co-Pilot/1st Officer Commercial 1310 1620
Last update 14 November 2018